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EMED Unit 1 > 3 Altered Mental Status and Toxicology > Flashcards

3 Altered Mental Status and Toxicology Flashcards

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1
Q

What exactly does mental status mean?

A

Assessment of level of patient awareness or consciousness (“behavioral expression of the brain”)

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2
Q

What does “A&Ox3” mean?

A

Alert and oriented to person, place, and time

Sometimes it’s x4, if they are aware of their situation

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3
Q

What should you put instead of A&Ox3 if you don’t actually ask the questions?

A

“Alert and appropriate”

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4
Q

When describing a patient’s level of consciousness, it is more useful to describe _______ and ______ rather than to use terms like stupor or obtunded

A

Patient’s spontaneous behavior and responses to stimuli

That’s because the other terms are vague and have no true quantifiable definition

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5
Q

Examples of the ranges of consciousness

A 
Alert 
Lethargic/somnolent
Obtunded
Stuporous/semicomatose
Comatose
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6
Q

What is the level of consciousness:

A patient who is awake and fully aware of surroundings, responds appropriately to normal stimuli

A

Alert

Does not imply capacity to focus attention

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7
Q

What is the level of consciousness:

A patient who is not fully alert and drifts off to sleep when not stimulated

Spontaneous movement decreased

Awareness limited

A

Lethargic or somnolent

Unable to pay close attention, loses train of thought constantly and consistently

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8
Q

What is the level of consciousness:

A patient who is difficult to arouse and when aroused is confused

A

Obtunded

Constant stimulation is required to elicit minimal cooperation

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9
Q

What is the level of consciousness:

A patient who does not rouse spontaneously, requires persistent and vigorous stimulation for very little response

A

Stuporous or semicomatose

When aroused, will moan or mumble

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10
Q

What is the level of consciousness:

A patient who is unarousable and unresponsive

A

Coma

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11
Q

The Glasgow coma scale grades coma severity according to what three categories?

A

Eye opening

Motor function

Verbal responses

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12
Q

Even when you are dead, what score do you get on GCS?

A

3 lol

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13
Q

What are the four levels for eyes on the GCS?

A

Spontaneous = 4

To voice = 3

To pain = 2

None = 1

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14
Q

What are the six levels for motor response on the GCS?

A

Obeys commands = 6

Localized to pain = 5

Withdraws to pain = 4

Flexor posturing (Decorticate) = 3

Extensor posturing (Decerebrate) = 2

None = 1

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15
Q

Flexion with addiction of arms and extension of the legs

A

Decorticate (flexor) posturing

Reflects destructive lesion in CORTICOSPINAL tract from CORTEX TO UPPER MIDBRAIN

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16
Q

Extension, addiction, and internal rotation of the arms and extension of the legs

A

Decerebrate (extensor) posturing

Associated with damage to CORTICOSPINAL tract at the level of BRAINSTEM (pons or upper medulla)

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17
Q

How to remember that Decorticate posturing is flexor

A

COR - hands over heart

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18
Q

______ posturing is worse than ________

A

Decerebrate is worse than Decorticate

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19
Q

What are the five levels for verbal response on the GCS?

A

Conversant and oriented = 5

Conversant and disoriented = 4

Uses inappropriate words = 3

Makes incomprehensive sounds = 2

None = 1

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20
Q

GCS was originally developed for __________

A

Trauma patients, specifically head injury

It is not as useful in conditions other than trauma

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21
Q

A GCS score of ____ or below for longer than 72 indicates a very poor prognosis

A

8

In ED, it is customary to intubate a patient with a GCS ≤8 b/c it is likely that they are unable to protect their own airway

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22
Q

The term “altered mental status” is imprecise and can be referred to as many things, such as…

A 
Delirium
Encephalopathy
Acute confusional state
Acute cognitive impairment
Neurocognitive disorder (ie dementia)
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23
Q

What is the new term for dementia?

A

Major neurocognitive disorder

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24
Q

What is the DSM-5 definition for Major Neurocognitive Disorder (formally dementia)?

A 
Significant cognitive impairment in at least ONE of the following domains:
Learning and memory
Language
Executive function
Complex attention
Perceptual motor function
Social cognition

Impairment must be ACQUIRED and represent SIGNIFICANT DECLINE

Cognitive deficits INTERFERE W/ INDEPENDENCE in ADLs

Cognitive deficits DO NOT OCCUR EXCLUSIVELY in the context of DELIRIUM

Cognitive deficits are NOT BETTER EXPLAINED BY ANOTHER MENTAL DISORDER

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25
DSM-5 for Delirium
DISTURBANCE IN ATTENTION and AWARNESS Disturbance develops OVER A SHORT PERIOD OF TIME (days, hours), tends to FLUCTUATE Additional disturbance in COGNITION The disturbances are not better explained by another preexisting, evolving, or established neurocognitive disorder, and not part of a COMA Hx, PE, or labs suggest disturbance is caused by a MEDICAL CONDITION, SUBSTANCE INTOXICATION/WITHDRAWAL, or MED SIDE EFFECT
26
A simpler definition of delirium
A disturbance of consciousness and altered cognition that develops of a short period of time Some are drowsy/lethargic, others agitated/confused Can include VISUAL HALLUCINATIONS, tremulousness, and myoclonus/asterixis
27
____________ are not characteristic of delirium
Focal or lateralized neuro findings
28
______% of older medical patients experience delirium at some point
~30% Usually during a hospitalization Incidence higher in those with advanced age and pre-existing brain disease
29
Mortality is _______ for a patient with a given medical condition PLUS delirium (compared to the patient who has the medical condition alone)
Approximately DOUBLE
30
What are the risk factors for delirium?
UNDERLYING BRAIN DISEASE (ie dementia, stroke, Parkinson’s) Age ≥80 Infection (UTI, PNA) Polypharmacy EtOH use Men>Women Multiple medical problems Fractures
31
Comparing Delirium and Dementia: Onset
Delirium = rapid Dementia = slow
32
Comparing Delirium and Dementia: Course
Delirium = Fluctuating Dementia = Progressive
33
Comparing Delirium and Dementia: Vital signs
Delirium = often abnormal Dementia = usually normal
34
Comparing Delirium and Dementia: Level of consciousness
Delirium = altered Dementia = normal
35
Comparing Delirium and Dementia: Hallucinations
Delirium = visual (related to external stimuli) Dementia = rare
36
Comparing Delirium and Dementia: Physical exam
Delirium = often abnormal Dementia = often normal
37
Comparing Delirium and Dementia: Prognosis
Delirium = Poor if not treated Dementia = Progressive
38
Comparing Delirium and Dementia: Underlying cause
Delirium = Organic (myriad) Dementia = Organic (degenerative)
39
AEIOU-TIPS
Common causes of AMS ``` Alcohol Epilepsy, endocrine, exocrine, electrolyte Infection Overdose, opioids, oxygen deprivation Uremia Trauma, temp, toxins Insulin Psychosis Stroke, shock ```
40
MOVE STUPID
Common causes of AMS ``` Metabolic Oxygen (hypoxia) Vascular (CVA, bleed, MI, CHF) Endocrine Seizure Trauma, temp, toxins Uremia Psychogenic Infection Drugs (intoxication or withdrawal) ```
41
What do you need to do to evaluate AMS?
Address ABCs first Assess vitals, mental status (GCS), pupil size, skin temp Check pulse ox, place on cardiac monitoring COMPLETE hx and PE to try to determine etiology (review MEDS) Start interventions (O2, finger-stick glucose, EKG, place IV/draw labs)
42
Reasonable starting labs for someone with AMS
Serum electrolytes, creatinine, glucose, calcium CBC UA (esp older patients) Pregnancy test EKG if CAD or >50 CXR if resp sx or fever Head CT if focal neuro findings or trauma ABG if hypoxic or metabolic acidosis suspected Lumbar puncture if meningitis/encephalitis suspected ALL WHILE PROVIDING AGGRESSIVE SUPPORTIVE CARE
43
What is key to the treatment of AMS?
Identifying and treating the UNDERLYING CAUSE
44
What three interventions should you consider in causes of AMS because they cause little to no harm in using them even if you’re wrong?
Thiamine Dextrose Naloxone
45
When should physical restraints be used for people with AMS?
Only as a LAST RESORT - really bad for the patient and makes them even less cooperative
46
What things can you do that can lessen disruptive behaviors in patients with AMS?
Frequent reassurance, touch, and verbal orientation A CAUTIOUS trial of psychotropic meds should be reserved for tx of severe agitation or psychosis with POTENTIAL FOR HARM to patients, providers or family
47
If you have a patient with AMS who is severely agitated and could potentially harm themselves or others, what drug can you try?
Low-dose haloperidol (better than Ativan esp in elderly pt)
48
In undifferentiated AMS, ___________ (drug) should generally be avoided
Benzodiazepines Consider in cases of sedative drug and alcohol withdrawal or sympathomimetic/anticholinergic poisonings
49
What is the exception to the rule about not giving bentos to someone with AMS?
Consider in cases of sedative drug and alcohol withdrawal or sympathomimetic/anticholinergic poisonings
50
_____________ are not effective in preventing or treating symptoms of delirium and often create undesirable side effects
Cholinesterase inhibitors (ie rivastigmine, donepezil)
51
Delirium may require _______ to fully resolve
Weeks or months
52
What is the American Association of Poison Control Centers national hotline phone number?
1-800-222-1222
53
What drug should you not forget contains acetaminophen?
Percocet!
54
What questions to ask when thinking about toxicology?
Which toxin was ingested, inhaled, or absorbed through the skin? How much was taken? When was it taken? What was the patient doing when ill?
55
What poisoning do you think of when someone has been working in a garage?
Carbon monoxide
56
What poisoning do you think of when someone has been fumigating a ship?
Cyanide
57
What poisoning do you think of when someone has been applying chemical to crops
Organophosphates
58
Someone who has had physiologic excitation would present with ...
CNS stimulation and elevations of HR, BP, RR, Temp
59
Someone who has had physiologic depression would present with ...
Depressed mental status and reductions in HR, BP, RR, Temp
60
Examples of substances that cause physiologic excitation
Anticholinergics (URI meds, atropine, some antidepressents) Sympathomimetics (cocaine, meth, bath salts and epi/NE) Central hallucinogen agents (PCP, LSD, MDMA) Drug withdrawal (EtOH)
61
Examples of substances that cause physiologic depression
EtOH, methanol, ethylene glycol Sedative-hypnotics (benzos, barbiturates) Opiates (narcotics/pain meds) Cholinergics (organophosphates) Sympatholytics (clonidine, beta/alpha blockers)
62
If mixed physiological effects, you should think...
Polydrug OD, exposure to metabolic poisons, heavy metals, or agents with multiple MOAs Ex - metformin, sulfonylureas, ASA, cyanide, iron, TCAs, mixing of street drugs
63
The _______ decontamination is performed, the more effective it is at preventing ___________
Sooner —> prevents poison absorption
64
How to decontaminate topical exposures
Copious water or saline irrigation (protect yourself during this!!!)
65
Should you use activated charcoal for decontaminating a patient who has ingested a toxic substance?
Less popular in recent years Ask poison control! Don’t do it unless it will HELP the patient and they can tolerate it
66
What are some other examples of GI decontamination besides activated charcoal?
``` Gastric lavage Whole bowel irrigation Endoscopy Surgery Dilution Cathartics ``` Consult a toxicologist to find out what to do!
67
What are some procedures that enhance elimination of a poison?
Forced diuresis Urine ion trapping Hemodialysis Exchange transfusion
68
What is the cornerstone of treatment for poisoning?
SUPPORTIVE CARE “Treat the patient, NOT the poison” In some instances though there are known antidotes that are potentially lifesaving
69
______ dramatically reduce morbidity and mortality in certain intoxications but they are unavailable for most toxic agents and therefore are used in only a small fraction of cases
Antidotes
70
What are some ways in which antidotes work?
Prevent absorption Bind and neutralize poisons directly Antagonize end-organ effects Inhibit conversion to more toxic metabolites
71
Toxicity may recur if the antidote...
Is eliminated more rapidly than the ingested substance Naloxone is a good example - reverses opioid effects but symptoms recur in approx. 1/3 of cases b/c the elimination half-life of naloxone is only 60-90 min and opioid half-life is longer Some antidotes may require repeated administration or continuous infusion
72
Just because you have an antidote, doesn’t mean you should always use it. Take flumazenil for example...
It’s an antidote for benzodiazepines but can precipitate seizures in patients who use benzos chronically
73
Antidote for acetaminophen
N-Acetylcysteine
74
Antidote for Amitriptyline
Sodium Bicarbonate
75
Antidote for anticholinergics
Physostigmine
76
Antidote for beta-blockers
Glucagon
77
Antidote for benzos
Flumazenil ****UNLESS**** they use benzos chronically (seizures)
78
Antidote for CCBs
Calcium!
79
Antidote for Coumadin
Vitamin K, FFP
80
Antidote for cyanide
Hydroxocobalamin/Nitrates
81
Antidote for Digoxin
Digoxin antibodies (Digibind)
82
Antidote for heparin
Protamine
83
Antidote for hydrofluoric acid
Calcium
84
Antidote for iron
Desferrioxamine
85
Antidote for methanol/ethylene glycol
Ethanol
86
Antidote for methemoglobin
Methylene blue
87
Antidote for opiates
Naloxone
88
Antidote for Organophosphates/anti cholinesterase SS
Atropine, 2-PAM
89
Antidote for salicylates
Urine alkalization, dialysis
90
Antidote for sulfonylureas
Octreotide
91
What toxic substances do you test for with urine drug screens?
``` Opioids Benzos Cocaine THC Barbiturates Amphetamines/methamphetamines TCAs Buprenorphine ```
92
What toxic substances do you test for with serum screening?
``` Acetaminophen Salicylate Carboxyhemoglobin Digoxin Lithium Iron, lead, mercury Ethylene glycol Antiepileptic drugs ```
93
How long are amphetamines detectable in urine?
2-3 days
94
How long is cocaine detectable in the urine?
2-3 days
95
How long is marijuana detectable in the urine?
1-7 days (light use) | 1 month with chronic moderate to heavy use
96
How long are opiates detectable in the urine?
1-3 days
97
How long is Phencyclidine detectable in the urine?
7-14 days
98
Signs/symptoms that occur consistently as a result of a particular toxin, clinically notable and distinguishable by changes in vital signs and end organ manifestations
Toxidrome
99
What labs should you do for ALL poisonings, toxidromes, and patients with AMS?
Serum pregnancy test in all women of childbearing age Fingerstick glucose to quickly rule out hypoglycemia Acetaminophen and salicylate testing to rule out common co-ingestion that can be fatal but have effective treatment strategies
100
Examples of cholinergics
``` Organophosphates and carbamate insecticides*** Nerve agents (sarin)*** Nicotine*** Pilocarpine Physostigmine Edrophonium Bethanechol Urecholine ```
101
What is the cholinergic toxidrome?
SLUDGE and the Killer Bs ``` Salivation Lacrimation Urination Defecation GI pain Emesis ``` Bradycardia, Bronchorrhea, Bronchospams Also, MIOSIS***
102
How do you treat cholinergic toxidrome?
Aggressive decontamination (get the agent OFF) Moderate to severe toxicity will usually require intubation ATROPINE, ATROPINE, ATROPINE - to help dry them up —> As much atropine as it takes (watch for pupils to dilate) Pralidoxime (2-PAM) for organophosphates
103
How does 2-PAM work?
Reactivates cholinesterase that had been inactivated by phosphorylation
104
Anticholinergic Toxidrome
Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone The bowel and bladder lose their town and the heart runs alone Causes: antihistamines, atropine, belladonna, jimson weed
105
Earliest and most reliable sign of anticholinergic toxidrome
Tachycardia (“the heart runs alone”) - but not very specific
106
How to treat anticholinergic poisoning
Control agitation with benzos Consider activated charcoal if ingestion was relatively recent (must have relatively normal mental status and good airway) PHYSOSTIGMINE - controversial but should be considered with poison control guidance
107
Sympathomimetic toxidrome
``` Hyperthermia Tachycardia/dysrhythmia HTN Diaphoresis Agitation, hallucinations, paranoia Dilated pupils Seizures (more common than with anticholinergics) ``` Examples: cocaine, amphetamines, bath salts, caffeine
108
What appears similar to a sympathomimetic toxidrome?
Alcohol withdrawal
109
First line treatment for sympathomimetic toxidrome
Benzos
110
Anticholinergics and sympathomimetics have very similar toxidromes EXCEPT...
Cutaneous: Sympathomimetic = diaphoresis, moist mucous membranes Anticholinergics = dry skin and mucous membranes GI: Sympathomimetic = hyperactive bowel sounds Anticholinergics = decreased or absent bowel sounds
111
Opioid toxidrome
“Cold depression” ``` Hypothermia Bradycardia and hypotension Bradypnea/apnea Flash pulmonary edema***(esp in younger patient) CNS depression, coma MIOSIS ```
112
Mainstay of treatment for opioid toxidrome
Supportive care and NALOXONE
113
For chronic narcotic users that are breathing, how should you administer naloxone?
Start with lower doses (0.4mg) to avoid precipitating withdrawal
114
Sedative-hypnotic toxidrome
``` Hypothermia Vitals usually relatively normal (maybe Brady/hypotension) Bradypnea/apnea CNS depression, coma Hyporeflexia*** VARIABLE pupils*** ``` Examples: Benzos, barbiturates, alcolol
115
What are roofies?
Flunitrazepam - 10x as potent as diazepam Can cause sedative-hypnotic toxidrome
116
How to treat sedative-hypnotic toxidrome
Supportive care - TINCTURE OF TIME Rarely - flumazenil (but can induce seizures in chronic benzo users)

EMED Unit 1 (5 decks)

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