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Emergency Medicine Module 3 > ALOC > Flashcards

Flashcards in ALOC Deck (33):
1

what is ALOC

  • Acute change in behavior, mentation, communication and/or level of consciousness
  • AMS = altered mental status
  • DDx in these pt’s is broad:
    • Infection
    • Intoxicated
    • Confused
    • Agitated, violent
    • Neurologic
    • Traumatic
    • Psychiatric

2

ED - decision

  • Altered patients are brought to us for:
    • Diagnosis, protection, stabilization, intervention, disposition
  • Why is the person acting this way?
    • New, acute process?
    • Acute on chronic process?
    • Chronic process - is patient at baseline?
  • Medical vs. Psychiatric
    • Organic = medical issue
      • Delirium vs. Dementia
    • Functional = psychiatric issue

3

Delirium vs dementia

  • Delirium
    • Disturbed level and content of consciousness
    • Easily distracted, poor attention span
    • Disorganized thinking
    • Rapid onset, fluctuates throughout day
    • “Islands of lucidity”
    • Psychomotor changes, hallucinations
  • Dementia
    • Normal level but altered content of consciousness
    • Gradual onset
    • Multiple cognitive defects: memory, language, attention, orientation, visual-spatial

4

psychiatric and mixed

  • Psychiatric
    • Slower onset, acute changes, exacerbations
    • VS? Otherwise - normal PE and neuro exam
    • Altered content, not level, of consciousness; fantasy vs reality
    • From agitated to catatonic
    • Delusions: complex, paranoid, religious
    • Disorganized, misplaced priorities, judgment
    • Auditory hallucinations
  • Mixed disorders
    • Extremely common
    • = Psych plus drug abuse
  • Patterns overlap
  • Add infection, drugs, trauma or metabolic issues to any of the above = a problem

5

ALOC ddx: AEIOU tips

  • Alcohol, withdrawal
  • Epileptic Seizure
    • Post-ictal state
  • Insulin (glucose)
  • Opiates, other drugs
  • Uremia, liver failure
  • Trauma
  • Infection
    • Especially the elderly
  • Psychiatric
  • Shock

6

Red flags in ALOC

  • Medical = sick, not just crazy
    • Persistently abnormal VS
      • Any fever, hypotension
    • Old/young/immunocomp
    • Findings on PE
      • Falls, trauma
      • Rash, stiff neck
      • Focal neuro findings
    • Evidence of/hx of seizure
    • Toxidrome/Intoxication
    • PMHx
    • Meds: old, new, OTC, CAM
  • Suspect delirium: characteristics
    • Rapid onset
    • Disorientation/short term memory loss
    • Fluctuating ALOC
    • Social immodesty
    • Sx’s increase at night
    • Visual hallucinations
  • Don’t forget EtOH w/d

7

approach to ALOC patient

  • ABCDE’s first
  • “ALOC Protocol” on everyone
    • Vital signs, including temperature
    • Undress
    • Dextrostik (fingerstick glucose)
    • Check pupils, skin, bowel sounds: look for toxidrome
    • EKG if tachy or brady
    • Alcohol level, UTox
    • Upreg
  • Can we reverse it? Glucose, narcan?

8

observation and information - ALOC

  • What do you hear?
    • Interaction with staff, paramedics
  • What do you see?
    • Safety first. Are they restrained? Should they be?
  • EMS information
    • Details of behavior on scene
    • Interventions en route
    • Condition of scene
      • Pill bottles, paraphernalia, disorder, chaos
  • Chief complaint?
  • 5150? Find & read the form
  • Detective work is critical
    • Past visits to this ED
    • Old medical record
    • Family, friends, associates
    • Nursing home, board and care staff
    • Records from other hospitals
  • Do they appear to have DMC?

9

history ALOC - simple, focused

  • What happened today?
  • Do you have pain anywhere?
  • Been sick lately?
  • Any medical problems?
  • Any injuries - fall, trauma?
  • Take medications? Are you taking them?
  • Have you used drugs or alcohol today?
  • Are you hearing voices?
    • What are they saying?
  • Seeing anything unusual?
  • Orientation questions
    • Know where you are?
    • How did you get here?
    • Do you know the date? Month? Year?
    • Who’s the president?
    • Make it relevant

10

history ALOC - family/friends

  • Onset fast or slow?
  • How different from normal?
  • When last seen normal?
  • Happened before?
  • PMHx, Medications? Psych Hx?
  • Recently ill, trauma?
  • Witnessed loss of consciousness?
  • Drug and alcohol hx?
  • Delusions, paranoia?
  • Recent emotional stress?
  • Past hx of suicide attempt?
  • Anything else that might help me take care of the patient?

11

Traumatic ALOC hx

  • Mechanism
  • When? Once or more?
  • Did you lose consciousness?
    • Before or after the injury?
  • What did you do after it happened?
  • How do you feel now? What hurts?
  • Headache? Vomiting?
  • Can you walk?

12

physical exam ALOC

  • Vitals: EMS, triage, repeat – VS are your friends
  • Appearance, undress, head to toe exam
    • Get permission, explain, go slow
    • Look for a toxidrome
  • Glascow Coma Scale – trauma
  • Mini-Mental Status Exam
    • If relevant and patient can cooperate
    • Orientation, Registration, Naming, Reading
  • Document if pt is unable to, or unwilling to cooperate with exam
  • Glascow Coma Scale (3-15) (best in trauma)
  • Dead people score a three; 9 or less = significant
    • Eye opening (4 pts) (“four eyes”)
      • Spontaneous, to voice, to pain, none (4-1)
    • Verbal (5 pts) (“Jackson 5”)
      • Oriented, confused, inappropriate, incomprehensible, none (5-1)
    • Motor (6 pts) (“6-cylinder engine”)
      • Obeys commands, localizes, withdraws, flexes, extends to pain, none (6-1)
  • APVU Scale: awake, verbal, pain, unresponsive
    • Also used in trauma

13

labs to consider ALOC

  • “ALOC Protocol”: vitals, d-stick, upreg, urine tox, EtOH on all
  • Urinalysis: blood, infection, ketones
  • CBC w/ diff, Chem Panel
  • Total CK – rhabdomyolysis (agitated, stimulants, down time)
  • Magnesium, phosphorus (etoh)
  • Tylenol, ASA level (OD’s)
  • Rx med levels (esp Sz meds, digoxin)
  • TSH, RPR, HIV in new psychosis
  • Consider lactic acid if fever, hypotension

14

diagnosis and treatment ALOC

  • IV hydration is good
    • Agitated, delirium, alcohol, tox: all are not eating/caring for self
  • Sedation/Tx – usually IM
    • Benzo’s: Versed 2-5mg IM Short acting
    • Geodon10-20mg IM or Zyprexa 5mg PO for psych pt’s
    • Visit sedated patients often!
    • Document course
  • Serial Exams
    • Monitor VS and mental status changes
    • Recognize if getting worse or better
  • CXR and EKG
  • Head CT
    • Traumatic ALOC
    • New delirium w/o cause or any new psychosis
    • HIV, CA + ALOC
  • Lumbar puncture
    • Fever and ALOC
    • HIV and ALOC
    • Consider in new delirium or psychosis
  • Charcoal? Antidote?
    • Consider if OD possible

15

psychiatric emergencies

  • Up to 12% of all ED visits - difficult pt’s
  • 50% <40yrs of age
  • Substance abuse common co-morbidity
  • Medical non-compliance
  • Homelessness, unstable social situation
  • Evening > Daytime
  • Brought in by police, EMS vs. self present
  • “5150”: Suicidal, homicidal, gravely disabled
  • ED “medically clears” pt’s on 5150 hold
    • ED must determine there is no medical/organic cause
    • Psych facility is not an acute medical facility!
  • We place pt’s on 5150 hold if appropriate, necessary. MD signs
  • We must decide if psych pt’s:
    • Can be discharged home
    • Need medical admission
    • Need psychiatric admission
  • Purely psychiatric cause of ALOC is a diagnosis of exclusion

16

what is "medical clearance"

  • Diagnosis established
  • Stable: no medical issues at transfer
    • Work up, injuries addressed, vitals normal
  • Pt is able to talk to psychiatrist
    • Sedated/intoxicated pt’s can’t be evaluated
  • Practitioner to practitioner transfer by phone – be ready
  • Arrange transportation (BLS)
  • Inform patient and family

17

approach to the patient

  • ABCDE’s, Vitals, ALOC Protocol, Sick or not Sick?
  • Protect the patient, protect the staff
  • History - detective work
  • Mental Status exam/Orientation
  • Physical Exam
  • Lab, diagnostics
  • Diagnosis
  • Disposition

18

history of psych emergency

  • Calm, non-judgemental, professional
  • What happened? Why are you here?
  • How did you get here?
  • Can’t get coherent Hx?
    • 5150 form
    • Paramedic run sheet
    • Hospital records
    • Family, friends, caretakers, witnesses
  • Past Medical Hx: Prior psych history? Any med problems?
  • Meds - big clue - are you taking them? OTC, CAM
  • Habits - anything today?
  • ROS – focus on the biggies
  • Social Hx
    • Life stressors, events, living situation
    • Has anyone hurt you lately?
    • Is there anyone I should call?

19

History for SI

  • Ask about/uncover suicidal ideation (SI) in all psych pt’s
    • Do you want to hurt yourself or anyone else?
    • Are you feeling suicidal now?
    • Have you thought about how you would do it?
    • Do you have: gun, access to pills, etc…?
    • Have you ever tried to hurt yourself before?
    • Are you hearing voices? What are they saying?
    • Are you seeing anything unusual?
    • Screening at triage is a Joint Commission imperative
      • Desire to be dead or not wake up...SI without plan....SI with plan, preparation, attempt...in the past month

20

 physical exam for SI

  • Vitals
  • General appearance
  • Head to toe exam – get permission
  • Orientation questions, Mini-Mental Status if able
  • Document if pt is unable or unwilling to cooperate with exam and why
  • May need to examine after sedation
  • Serial exams

21

medical workup

  • Who gets a medical workup?
    • No previous psych Hx
    • Age >40 - first psych issue
    • Abnormal vital signs
    • Recent memory loss, trauma
    • Impaired consciousness
    • Focal neurologic finding
  • You suspect an organic, not functional etiology of this behavior change
  • Everybody - D-stick, Upreg, Utox
  • Specific patients consider:
    • CBC, Chem panel, UA, serum etoh
    • Rx drug levels, Tylenol, ASA
    • TSH, RPR
    • EKG, CXR
    • Consider creatinine kinase – especially w/ stimulants – high CK = rhabdomyolysis
    • Consider lactic acid if fever, hypotension, infection
    • Consider head CT, lumbar puncture if new, different, fever

22

violent patients

  • Predictable and unpredictable
  • Listen: the obvious and your gut
  • Inappropriate patients should be treated with great care, apprehension
  • Assessment from safe distance
    • Know your space
    • Exam with another person at bedside or within view

23

restraints

  • Protect the patient, protect the staff
  • Try talking pt down – once
  • Decide, inform, then act as one
  • Mechanical
    • Soft restraints, leathers, belts, mask
  • Chemical
    • Benzodiazepines
      • Midazolam (Versed) 2-5mg IM/IV*
      • Lorazepam (Ativan) 1-2mg IM/IV
    • Antipsychotics
      • Ziprasidone (Geodon) 10-20mg IM, 20mg PO
      • Haloperidol (Haldol) 2-5mg IM/IV
        • Add Cogentin 1-2mg IM/IV, extrapyramidal effects
  • Restraint rules
    • Must have legitimate reason to restrain, must fill out form
    • Restrain pt’s with other staff assisting
    • Remove restraints with other staff present
    • Never remove restraints from any patient you do not know
    • Restrained pt’s must be supervised
    • Contracts with patients - beware!
    • Speak to the family about restraints

24

suicide

  • Risk factors
    • Male, white, unemployed, single
    • Adolescents
    • Drug and/or alcohol abuse
    • Recent life stressor
    • Physical/chronic illness
    • Hx domestic violence, sexual assault/abuse
    • Major mood disorders, 10% schizophrenic pts
    • Lethality/Rescue ratio of plan
    • Past attempt, family Hx of suicide

25

treatment of suicidal pts

  • Recognition, assess risk, 5150?
  • Suicide precautions in ED
    • Restraints, high visibility area, “clean” area
  • Medically clear
    • Monitor, treat, consider overdose
    • Repair lacerations, hydrate, etc...
  • Psychiatric consult by phone or in person
  • Admit to hospital or transfer to psych facility
    • Transfers must be stable!

26

discharging suicidal pts

  • Psychiatric/Attending MD consultation obtained, agree
  • Not suicidal now
  • Risk profile low
  • Intent, gesture for secondary gain
  • Pt has family, friends here, now
  • Pt has stable home environment
  • Can f/u with psychiatrist reliably
  • Means of lethality eliminated or regulated

27

depression

  • Epidemiology
    • Most common psych disturbance – situation, illness, meds, drugs
    • Most common underlying cause of suicide
    • Most costly to society
    • Genetic disposition
    • Modern complications
      • Media, world events
      • Immigrant displacement
  • SIG-ME-CAPS
    • Sadness
    • Insomnia/Hypersomnia
    • Guilt
    • Mood
    • Energy
    • Concentration
    • Appetite, activity
    • Pleasure (anhedonia)
    • Suicide

28

ED evaluation of depression

  • Patient a danger to themselves or others? Need a 5150?
  • Organic or Functional or Situational?
  • Diagnostics
    • ALOC Protocol, add TSH
  • Disposition based on severity
    • Suicide risk, ability to care for self, support
    • ED rarely initiates medical therapy (2 week rule)
    • Discuss therapies – drugs help, medical model

29

mania eval/treatment

  • “Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week”
  • Psychiatric, medical, medications, drugs
  • Patient a danger to themselves/others?
  • Protect patient, protect staff
    • Chemical restraint often needed – Benzo’s
  • Good history/PE - get info
  • Medical work-up if new, unstable
  • ALOC Protocol, add EKG, TSH, CK
  • Psychiatric consult, 5150?

30

anxiety - differential dx

  • Really common; huge DDx
  • Cardiac - MI, CHF, dysrhythmias
  • Endocrine – thyroid, etc
  • Respiratory - PE, asthma, COPD
  • Drugs
    • Sympathomimetics, caffeine, herbals, cannabis, LSD, ecstasy, benzo’s
    • ETOH, opiate/benzo withdrawal
    • Formication
  • Psychiatric
    • Mania, depression, schizophrenia

31

anxiety eval/tx

  • Patient a danger to themselves/others?
  • Evaluate in quiet area, listen, reassure
  • Good history, good physical
  • ALOC Protocol
  • EKG if tachy, chest pain; TSH
  • Treatment
    • Benzo’s IV, IM, PO
    • Primary care referral, psych if danger to self
    • Referrals for counseling, groups, etc
    • Benzo Rx only for 3-5 days max if discharged

32

schizophrenia

  • <3% population but common in ED
  • Medication non-compliance
  • Frequent SI
  • Mixed disorders, substance abuse
  • Recent stressors
  • Poor support/situation
  • No regular psych treatment
  • Danger to themselves/others? 5150?
  • Protect the patient, staff
  • May need chemical restraint, treatment
    • Benzo’s
    • Geodon, Haldol, Zyprexa to tx sx’s - voices, agitation
  • Good history/PE - get info
  • New = medical work-up
  • Not new? What caused this change?
  • Psych consult, follow-up

33

SE's of typical antipsychotics

  • Dystonic Reaction à
    • Buccolingual, oculogyric, neck
    • Benadryl - acute IV, outpt PO
  • Tardive Diskinesia
    • Involuntary: lips, face, extrem
  • Orthostatic Hypotension
  • Neuroleptic Malignant Syndrome
    • ALOC, fever, “lead pipe” rigidity, autonomic instability - rare – sick - admit
  • Serotonin Syndrome
    • ALOC, fever, tremor/shakes, rigid LE’s, hyperreflexia