Altered Mental Status and Toxicology Flashcards Preview

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What is mental status?

Assessment of level of pt awareness or consciousness
A&O X 3 (4 when situation)


More appropriate way to document mental status

Alert and appropriate or following commands


Levels of consciousness

Stepwise progression from alert to comatose with lethargic, obtunded and stuporous in between
--better to just describe pts spontaneous behavior and responses to stimuli tho


Definition of alert

Awake and fully aware of surroundings
Responds appropriately to normal stimuli
*does not imply capacity to focus attention


Definition of lethargic/somnolent

Not fully alert and drifts off to sleep when not stimulated
Decreased spontaneous movements
Limited awareness
Unable to pay close attention, constantly and consistently loses train of through


Definition of obtunded

Difficult to arouse and is confused when aroused
Constant stimulation required to elicit minimal cooperation


Definition of stuporous or semicomatose

Does not arouse spontaneously
Requires persistent and vigorous stimulation for very little response
Moans or mumbles when aroused


Definition of coma

Unarousable unresponsiveness


Categories of responsiveness on GCS

-grades coma severity
Eye opening, motor and verbal responses


Minimum GCS you can get

3 (when they are dead/deep coma)


Eye opening on GCS

4- spontaneous
3- to voice
2- to pain
1- none


Motor response on GCS

6- obeys command
5- localizes to pain
4- withdraws to pain (cringing)
3- flexor posturing
2- extensor posturing
1- none


Verbal response on GCS

5- conversant and oriented
4- conversant and disoriented
3- inappropriate words
2- incomprehensible sounds
1- none


What is decorticate posturing?

Flexion with adduction of arms and extension of legs--flexor response (COR is hands over heart)
Reflects destructive lesion in corticospinal tract from cortex to upper midbrain


What is decerebrate posturing?

Extension, adduction and internal rotation of arms and extension of legs--extensor posturing
**worse than decorticate
Reflects damage to corticospinal tract at level or brainstem (pons or upper medulla)


What is GCS usually used for?

Trauma pts (head injury)
Lower number is worse prognosis (very poor if 8 or below longer than 72 hrs)


When do you intubate based on GCS?

< or = 8 b/c probably cannot protect airway


What is major neurocognitive disorder also called?



Definition of dementia

Significant cognitive impairment in AT LEAST one of following (learning and memory, language, executive function, complex attention, perceptual motor function and social cognition)


DSM-5 criteria for dementia

Evidence of significant cognitive decline in 1 or more domains
Acquired impairment and is declining from previous functioning
Deficits interfere with independence in every day life
Deficits not occurring in context of delirium
Deficits not better explained by another disorder


DSM-5 criteria for delirium

Disturbance in attention and awareness
It develops in short period of time and is change from baseline (usually fluctuates during day)
An additional disturbance in cognition
Not better explained by preexisting, evolving or established neurocognitive disorder or not in context of reduced level or arousal
Evidence it is caused by medical condition, substance intoxication/withdrawal or med side effect


So basically what is delirium?

Disturbance of consciousness and altered cognition over short period of time (maybe drowsy or agitated)


Why is delirium important?

Older pts will probs experience it
Morbidity and mortality high in these pts!
Mortality almost doubles when pt has medical condition and delirium!


Risk factors of delirium

MOSTLY underlying brain disease (dementia, stroke, Parkinsons)
EtOH use
Multiple med problems


Major exam findings to differentiate delirium and dementia

Delirium- rapid onset, abnormal vitals and PE, visual hallucinations, poor prognosis
Dementia- slow, normal exam usually


How to examine for AMS?

Vitals, GCS, pupil size, skin temp
Pulse ox and cardiac monitoring
Complete history and PE (meds)
Start interventions: O2, glucose, EKG, IV and labs


What are some good diagnostic tests to start with in AMS?

Electrolytes, creatinine, glucose, calcium CBC, UA and pregnancy


How to treat AMS?

ID and treat underlying cause
Meanwhile, consider thiamine (alcoholic), dextrose (low blood sugar) or naloxone (if narcotic OD possible)-- little to no harm if these are used incorrectly


How to control aggressive behaviors associated with AMS

Physical restraints are last resort
Touch, reassurance and orientation from familiar ppl can help
Only use antispychotics when there is agitation that may lead to harm on other ppl (haloperidol)


What to avoid with undifferentiated AMS

Benzos (only consider with sedative or alcohol withdrawal or sympathomiment/anticholingeric poisonings)