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Surgery and Emergency Med > Altered Mental Status + Toxicology > Flashcards

Altered Mental Status + Toxicology Flashcards

(114 cards)

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1
Q

range of consciousness

A

alert

lethargic or somnolent

obtunded

stuporous or semicomatose

comatose

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2
Q

what level of consciousness

awake and fully aware

responds appropriately

+/- ability to focus attention

A

alert

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3
Q

what level of consciousness?

not fully alert and drifts off to sleep with not stimulated

spontaneous movements decreased

awareness limited

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

A

lethargic

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4
Q

what level of consciousness?

difficult to arouse, confused

stimulation required to elicit minimal cooperation

A

obtunded

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5
Q

what level of consciousness?

does not rouse spontaneously

requires vigorous stimulation with little response

when aroused will moan, mumble

A

stuporous

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6
Q

what level of consciousness?

unarousable unresponsiveness

A

coma

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7
Q

what grades coma severity according to three categories

A

glasgow coma scale

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8
Q

what three categories in glasgow coma scale

A

eye opening

motor responses

verbal responses

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9
Q

if you are dead, what do you score on GCS

A

3

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10
Q

GCS step 1: eye opening

what is a 4, 3, 2, and 1?

A

4 - spontaneous eye opening

3 - responds to speech

2 - responds to pain

1 - no response

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11
Q

GCS step 2L
motor response

what is 6, 5, 4, 3, 2, 1?

A

6 - obeys motor commands

5 - localizes motor demands

4 - withdrawals

3 - abnormal flavor responses

2 - extensor response

1 - no response

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12
Q

flexor response (score 3) - what kind of posturing

A

decorticate posturing

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13
Q

what is decorticate posturing?

A

flexion with adduction of arms and extension of legs (COR - hands over heart)

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14
Q

what does decorticare posturing indicate?

A

destructive lesion in corticospinal tract from cortex to upper midbrain

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15
Q

what is extensor posturing (score of 2 for motor movements)?

A

decerebrate posturing

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16
Q

what kind of posturing?

extension, adduction, and internal rotation of the arms and extension of legs

A

decerebrate

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17
Q

what is decerebrate posturing associated with

A

damage to corticospinal tract at level of brainstem (pons, upper medulla) - primative stuff

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18
Q

damage at brainstem

A

decerebrate posturing

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19
Q

damage at cortex to upper midbrain

A

decorticate posturing

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20
Q

GCS - verbal response

5, 4, 3, 2, 1

A

5 - oriented

4 - confused conversation (say wrong year when asked what year it is)

3 - inappropriate words

2 - incomprehensible sounds

1 - no response

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21
Q

GCS of 15 - means what

A

wide awake and appropriate

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22
Q

GCS of 3 means what

A

dead or deep coma

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23
Q

when is GCS most useful

A

trauma

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24
Q

GCS - lower number assoc with

A

worse prognosis

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25
if GCS of 8 of 72 hours or longer - what does that mean
very poor prognosis
26
what do you do if GCS is 8 or less
INTUBATE - protect airway
27
Demenia DSM definition
sig cog impairment in at least one of the following: learning and memory, language, executive function, complex attention, perceptual motor function, and social cognition
28
Major neurocognitive disorder DSM 5 criteria
cog decline in 1+ domains impairment is acquired and represent sig decline from previous functioning interferes with independence does not occur exclusively in context of delirium not better explained by another mental disorder
29
5 key features of delirium
disturbance in attention and awareness develops over short period of time fluctuates throughout day additional disturbance in cognition not better explained by other neurocog disorder disturbance is caused by medical condition, substance intox or withdrawal, or med side effect
30
are focalized or lateralized neurologic findings characteristic of delirium
NOPE
31
visual or auditory hallucinations with delirium
visual
32
mortality ____ for a pt with a given medical condition plus delirium
doubles
33
delirium number 1 risk factor
underlying brain disease
34
other risk factors for delirium
80+ infection polypharmacy ETOH use men multiple medical issues fractures
35
5 steps in evaluation of AMS
1. ABCs 2. Vitals, mental status (GCS), pupil size, skin temp 3. pulse ox, cardiac monitoring 4. complete hx and phys exam 5. start interventions
36
what interventions should be started with AMS immediately
oxygen glucose EKG place IV/draw labs
37
additional workup for AMS: what serology tests
electrolytes creatinine glucose calcium CBC UA pregnancy
38
diagnostic workups for AMS: EKG
if CAD history or over 50
39
dx workup for AMS: CXR
if resp symptoms or fever
40
dx workup for AMS: head CT
if focal neuro exam findings or hx of trauma
41
dx workup for AMS: ABG
hypoxic or metabolic acidosis (esp with COPD pts)
42
what other diagnostic work-up for AMS
TSH, folate, vit B12, blood alcohol, urine drug screen, specific drug levels
43
dx workup for AMS: lumbar punction
if meningitis/encephalitis are suspected
44
tx AMS
identify and tx underlying cause in the mean time: thiamine dextrose - blood sugar is low naloxone if narcotic overdose is possible
45
should you use physical restraints with AMS
last resort only pharmacological restraint - low dose haldol (esp in older patients)
46
are benzos part of tx in undifferentiated AMS
avoided - rough symptoms for elderly
47
are cholinesterase inhibitors effective at prevention or treatment of delirium
nope
48
how long does it take delirium to fully resolve
weeks or months
49
questions to ask when toxins are considered
which toxin how much when what was pt doing when he/she became ill
50
what four things can cause CNS stimulation and elevation of HR, BP, RR, and temp
anticholinergics sympathomimetics central hallucinogen agents drug withdrawal
51
examples of anticholinergics
URI meds - dextromethoraphan atropine some antidepressants
52
examples of sympathomimetics
cocaine meth bath salts epi/norepi
53
central hallucinogen agents exams
PCP LSD MDMA
54
drug withdrawal that can lead to CNS stimulation
ETOH
55
What things can cause physiologic depression?
ETOH + methanol + ethylene glycol intox sedative-hyponotics opiates cholinergics sympatholytics
56
depressed mental status and reduced HR, BP, RR, temp
physiologic depression
57
what is assoc with mixed physiologic effects
polydrug ODs, exposure to metabolic poisons, heavy metals, agents with multiple mechanisms of action
58
what drugs can cause mixed physiologic effects
metformin sulfonylureas aspirin cyanide iron TCAs mixing of street drugs
59
the _____ decontamination is performed, the _____ it is at preventing poison absorption
sooner more effective
60
topical exposures - decontamination
copious water or saline irrigation
61
ways of enhanced elimination for decontamination
forced diuresis urine ion trapping hemodialysis exchange transfusion
62
what is the cornerstone of toxicology tx
SUPPORTIVE CARE
63
antidotes may do what four things
prevent absorption bind and neutralize poisons directly antagonize end-organ effects inhibit conversion to more toxic metabolites
64
when can toxicity recur with antidotes
when antidote is eliminated more rapidly so repeated administration is needed
65
should you always use antidotes give an example of your answer
NO flumazenil for benzo reversal can precipitate seizures in chronic benzo users
66
antidote for acetaminophen
n-acetylcysteine
67
antidote for amitriptyline
sodium bicarb
68
antidote for anticholinergic
physostigmine
69
antidote for beta blockers
glucagon
70
antidote for benzos
flumazenil
71
antidote for calcium channel blockers
calcium
72
antidote for coumadine
vitamin K, FFP
73
antidote for cyanide
hydroxocobalamin
74
antidote for digoxin
digoxin antidote
75
antidote for heparin
protamine
76
antidote for hydroflouric acid
calcium
77
antidote for iron
desferrioxamine
78
antidote for methanol/ethylene glycol
ethanol
79
antidote for methemoglobin
methyline blue
80
antidote for opiates
naloxone
81
antidote for organophosphates
atropine, 2-PAM
82
antidote for salicylates
urine alkalization, dialysis
83
antidote for sulfonylureas
octreotide
84
opiods benzos cocaine THC barbituates amphetamines TCAs buprenorphine what test
urine drug screen
85
acetaminophen salicylate carboxyhemoglobin digoxin lithium iron/lead/mercury ethylene glycol antiepileptic drugs what test
serum screening
86
signs/symptoms that occur consistently as a result of a toxin what is this
toxidrome
87
changes in _____ and _____ are part of toxidromes
changes in vital signs end-organ manifestations
88
labs for ALL pts with AMD
pregnancy test glucose acetaminophen and salicylate testing
89
what am i describing? clammy skin vomiting/diarrhea lots of eye/nose discharge BRADYcardia pinpoint pupils
cholinergic
90
cholinergic toxidrome caused by
organophosphate and carbamate insecticides, nerve agents (sarin), nicotine, pilocarpine, physostigmine, edrophonium, bethanechol, urecholine
91
DUMBELS: cholinergic toxidrome
Defecation Urination Muscle weakness Bradycardia, bronchorrhea, bronchospasms Emesis Lacrimation Salivation
92
SLUDGE and Killer Bs: cholinergic toxidrome
``` Salivation Lacrimation Urination Defecation GI pain Emesis ``` Bradycardia, bronchorrhea, bronchospasms
93
dx of cholinergic toxidrome
clinical
94
tx of cholinergic toxidrome
aggressive decontamination ASAP atropine for symptom control 2-PAM - antidote
95
reactivates cholinesterase
2-PAM
96
blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone what toxidrome
anticholinergic
97
causes of anticholinergic toxidrome
antihistamines (URI drugs) Jimson weed Scopalamine
98
symptoms of anticholinergic toxidrome
hyperthermia dry, flushed skin dilated pupils agitation, hallucinations, delirium tachycardia HNT urinary retention decreased bowel sounds (can't pee, can't poop)
99
earliest and most reliable signs of anticholinergic toxidrome
tachycardia ALSO NON-SPECIFIC
100
dx of anticholinergic poisoning
clinical
101
tx of anticholinergic poisoning
control agitation with benzos consider activated charcoal if recent (MUST have normal mental status to protect airway) physostigmine - antidote - should be considered in mod/severe poisoning
102
hyperthermia tachycardia HTN diaphoresis agitation, hallucinations, paranoia dilated pupils seizures waht toxidrome
sympathomimetic
103
difference between anticholinergic and sympathomimetic toxidromes?
anticholinergic - DRY SKIN; hypoactive bowel sounds SYMPATHOMIMETICS - DIAPHORESIS (WET SKIN); hyperactive bowel sounds; seizures too! more common than with anticholinergics
104
causes of sympathomimetic toxidromes
cocaine amphetamines ephedrine pseudoephedrine bath salts theophylline caffeine
105
mimics fight or flight alcohol withdrawal also can mimic this what toxidrome?
sympathomimetic
106
tx of sympathomimetic toxidrome
benzos supportive care
107
hypothermia bradycardia hypotension bradypnea/apnea pulm edema CNS depression, coma miosis what toxidrome
opioid
108
flash pulm edema with normal sized heart - think what
heroin
109
tx of opioid
naloxone duration of action is 45 min so may need to repeat dosing
110
for chronic narcotic users - what do you do?
start with lower doses (.4 mg) to avoid precipitating withdrawal
111
what toxidrome hypothermia vitals normal bradypena/apnea CNS depression and coma hyporeflexia variavle pupils
sedative-hypnotic
112
causes of sedative hypnotic toxidrome
benzos, barbituates, GHB, alcohols, flunitrazepam (roofie in europe/mexico)
113
tx of sedative-hyponotix toxidrome
supportive care rarely flumazenil
114
why is flumazenil not used in sedative-hypnotic toxidrome tx
induces seizures in chronic benzo users

Surgery and Emergency Med (6 decks)

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