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Foundations II-Neurology > AMS > Flashcards

AMS Flashcards

1
Q

Other names for AMS?

A

ALOC, encephalopathy, confusion, delirium, acute cognitive impairment, neurocognitive disorder, organic brain syndrome

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2
Q

What is meant by level of consciousness? What is it impaired by?

A

measurement of response to stimuli and arrousability

impairment caused by bi cerebral dysfunction or within the RAS

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3
Q

Range of LOC?

A

Alert

Lethargic/somnolent

Obtunded

Stuporous/semi comatose

Comatose

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4
Q

Does alert imply capacity to focus attention?

A

NO

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5
Q

Describe lethargic or somnolent

A

not fully alert and drifts off to sleep when not stimulated

spontaneous movements decreased

awareness limited

unable to pay close attention

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6
Q

Describe obtunded

A

dif. to arouse and confused when aroused

constant stimulation req. to elicit minimal cooperation

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7
Q

Describe Stuporous/semicomatous

A

dose not rouse spontaneously, requires persistent and vigorous stimulation

when aroused will moan or mumble

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8
Q

Typical GSC for pts in Comatose state?

A

usually less than 8

if less than 8 then intubate

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9
Q

Persistence of delirium leads to…

A

poor long term outcomes

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10
Q

What is delirium?

A

disturbance in attention and awareness

develops over a short period of time

+ disturbances in cognition

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11
Q

Risk factors for delirium?

A

age, male gender, dementia, func. impairments in ADLs, medical comorbidities, hx of excessive ETOH use, sensory impairment (vision, hearing)

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12
Q

What can precipitate delirium?

A

Acute card/pulm events, bed rest, drug withdrawal, fecal impaction, fluid/electrolyte disturbances, indwelling devices, infx, meds, restraints, severe anemia, uncontrolled pain, urinary retention

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13
Q

How do we manage delirium?

A
  1. Prevention- avoid causes/precipitating factors
  2. Identify & tx reversible contributors
  3. Maintain behavioral control -sitter/fam, sleep/wake cycles, reorientation, reassurance, music, AVOID restraints
  4. Prevent complications
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14
Q

What can you give to maintain behavioral control if absolutely necessary?

A

Haloperidol

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15
Q

Drugs to reduce/eliminate in delirium pts?

A

alcohol, anticholinergics, anticonvulsants, antipsychotics, barbiturates, benzos, H2 blocking agents, opioids

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16
Q

Presentation of AMS?

A

confusion, lethargy, memory impairment, personality change, combativeness, agitation, etc.

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17
Q

Common causes of AMS?

A

AEIOU TIPS

alcohol and other toxins

endocrine and environmental factors

Insulin poisoning

Oxygen deprivation

uremia

trauma

infection

psychiatric causes

space occupying lesions

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18
Q

What is the most common electrolyte abnormality in AMS?

A

hyponatremia

also consider hypercalcemia

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19
Q

If pt has AMS secondary to head trauma what do you need to assess for?

A

spinal cord injury –> protect the spine

  • CT head/c-spine
  • rectal exam
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20
Q

Skin temp in hypothermia? physiologic responses?

A

near 91 F

peripheral vasoconstriction, shivering, AMS, CV and res changes

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21
Q

What is heat exhaustion? signs?

A

core temp may be normal or <106

orthostatic hypotension, tachycardia, sweating

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22
Q

What is a heat stroke?

A

core temp above 106F

same signs as heat exhaustion (orthostatic hypotension, tachycardia, sweating)

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23
Q

What should you think of as cause of AMS in very young or very old until proven otherwise?

A

Infection!

elderly: UTI, pna
infants: meningitis

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24
Q

What should you assess first in a pt presenting with AMS?

A

ABC
-airway, breathing, circulation

then:
VS, mental status, pupil size, skin temp

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25
Q

Tx of AMS

A

Identify and tx underlying cause

+ SNOT cocktail

  • Sugar (Glucose)
  • Naloxone (Narcan)
  • Oxygen
  • Thiamine (given prior to glucose to avoid inducing Wernicke-Korsakoff syndrome)
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26
Q

What drugs are associated with Physiologic excitation? (CNS stimulation and increased HR, BP, RR, temp)

A

anticholinergics, cocaine, meth, bath salts, PCP, ETOH withdrawal

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27
Q

What drugs are associated with physiologic depression? (depressed MS and decreased HR, BP, RR and temp)

A

ETOH, sedatives-hypotonics, cholinergics, pain meds, benzos

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28
Q

OD of which drugs can you mixed physiologic effects?

A

polydrug OD, heavy metals, Metformin, sulfonylurea, ASA, cyanide, iron, TCAs

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29
Q

Which toxins produce a fruity odor? Rotten egg odor?

A

Isopropanol, ETOH, DKA

hydrogen sulfide

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30
Q

What labs should you order in a pt with AMS?

A 
CBC 
electrolytes with anion gap 
BUN 
Creatinine 
Glucose 
LFTs
HCG 
UDS
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31
Q

Reasons for a high anion gap?

A

MUDPILES:

Methanol 
Uremia 
DKA 
Paraldehyde 
Infection 
Lactic Acidosis 
Ethylene Glycol 
Salicylates
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32
Q

What is a toxidrome?

A

a clinical syndrome, constellation of signs//sxs that suggest a specific class of poisoning

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33
Q

Which toxidromes cause mydriasis?

A

pupillary dilation:

  • sympathomimetic
  • anticholinergic
  • hallucinogenic (usually)
  • serotonin syndrome
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34
Q

Which toxidromes cause miosis?

A

pupillary constriction:

  • opioids
  • sedative-hypotonic (usually)
  • cholinergic
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35
Q

What are some examples of sympathomimetics? Signs/sxs?

A

Amphetamines and cocaine

  • psychomotor agitation, restlessness, anxiety
  • piloerection (goosebumps), mydrasis, diaphoresis, tachycardia, HTN, hyperthermia
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36
Q

What are some anticholinergics? sxs of anticholinergic toxicity?

A

antihistamines, TCAs, phenothiazines

Hot as a hare > fever

Blind as a bat > mydriasis

Dry as a bone > dry mm, urinary retention

Red as a beet > flushing

Mad as a hatter > psychosis

-Prolonged QT

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37
Q

Risk associated with long QT interval? Tx?

A

Torsades de pointes

give Mg

38
Q

Tx for anticholinergic toxicity?

A

alkalization (NaHCO3 for polycyclic antidepressant poisoning and for conduction abnormalities

39
Q

Sxs of cholinergic toxicity?

A

SLUDGE + killer B’s:

Salivation 
Lacrimation 
Urination 
Defecation 
GI pain 
Emesis 
Bradycardia, bronchorrhea, bronchospasms
40
Q

Why is OD of Acetaminophen so dangerous?

A

It is metabolized to a toxic intermediate N-acetyl benzoquinoemine (NAPQI) which is then detoxified by glutathione

potentially fatal secondary to acute hepatic failure

41
Q

Sxs of Acetaminophen OD?

A

usually asxs during first 24 hours +/- N/V

then S/S of liver injury

42
Q

Interventions for Acetaminophen OD?

A

activated charcoal, N-actetylcysteine, liver transplant

43
Q

Ex. of salicylates? sxs ?

A

ASA, oil of wintergreen (methyl salicylate), Pepto Bismol

AMS, respiratory alkalosis, metabolic acidosis, tinnitus, tachycardia, tachypnea,diaphoresis, N/V, fever

potentially fatal secondary to pulmonary edema or cardiopulmonary arrest

44
Q

Interventions for salicylate OD?

A

activated charcoal, hydration, hemodialysis

45
Q

Ex. of hypoglycemic agents? Sxs?

A

sulfonylureas, insulin

AMS, diaphoresis, tachycardia, increased BP, slurred speech

potentially fatal secondary to seizures

46
Q

Interventions for hypoglycemic agents OD?

A

glucose, freq. BS monitoring

47
Q

Sources of methanol and ethylene glycol?

A

wood alcohol, antifreeze, washer fluid, paint stripper

rapidly and completely absorbed after ingestion

48
Q

Sxs of Methanol and ethylene glycol OD?

A

like ETOH intoxication

blurred vision and blindness (methanol)

flank pain and hematuria (ethylene glycol) - calcium oxalate crystals in the urine are characteristic

potentially fatal 2/2 profound metabolic acidosis, renal failure and seizures

49
Q

Interventions for methanol and ethylene glycol ingestion?

A

Fomepizole, thiamine, folic acid or pyridoxine, ethanol, sodium bicarb, HD

50
Q

What are synthetic cannabinoids?

A

analogs of natural cannabinoids that are chemically synthesized

“incense”, “spice”, “K2” “chill out”

will NOT be detected on UDS

51
Q

sxs of synthetic cannabinoids?

A

tachycardia, slurred speech, conjunctival injection, nystagmus, N/V, ataxia, AMS< hallucinations, paranoia, seizures

52
Q

Tx for synthetic cannabinoids OD?

A

supportive care

benzos

53
Q

What are bath salts? sxs?

A

a cathinone, which is a beta ketone amphetamine analog -synthetic form

AMS, tachycardia, increased BP, fever, mydriasis, agitation, anxiety, seizures, hallucination, paranoia

54
Q

Interventions for bath salts OD?

A

supportive care, benzos

55
Q

Sxs of significant opioid OD?

A

depressed consciousness and eventually coma

miosis

hypotension and bradycardia > cardiopulmonary arrest

56
Q

S/S of alcohol withdrawal? Tx?

A

autonomic hyperactivity: diaphoresis, tachycardia

tremors, insomnia, hallucination, N/V, anxiety, seizures, loss of appetite

Tx: benzos

57
Q

What is delirium tremens? Tx?

A

due to alcohol withdrawal > med emergency due to extreme autonomic hyperactivity with delirium

Tx: IVF, thiamine, benzodiazepines

58
Q

What is wernicke’s encephalopathy? What is it associated with?

A

med emergency caused by acute thiamine deficiency

sxs: ophthalmoplegia, ataxia and confusion

Assoc. with: alcoholism and malnutrition

59
Q

Tx of wernicke’s encephalopathy?

A

thiamine and multivitamin

failure to recognize and tx may result in death or permanent neuro impairment

60
Q

When can gastric lavage be used for ingestion?

A

if ingestion occurred less than 60 mins earlier and the airway is protected

61
Q

Characterisitics of CO? When should you suspect poisoning?

A

colorless, oderless, tasteless, non-irritating

whenever a pt has suffered burns in a poorly ventilated area

DONT rely on pulse ox, carboxyhemoglobin causes it to be overestimated

62
Q

Sxs of CO poisoning?

A

HA, dizziness, dyspnea, fatigue, CP, confusion

cherry red skin coloring

63
Q

Common source for poisoning in AZ? Tx?

A

recreational boating, esp. houseboats

All pts on 100% O2, some should receive hyperbaric oxygen

64
Q

Antidote for Acetaminophen? Anticholinersterases?

A

N acetyl cysteine

Atropine

65
Q

Antidote for Benzodiazepines? beta blockers?

A

Flumazenil but may cause seizures

Glucagon

66
Q

Antidote for CCBs? CO? Opioids?

A

Calcium

Oxygen

Narcan

67
Q

What is a concussion?

A

A complex pathophysiological process affecting the brain, induced by traumatic mechanical forces

rapid onset of neuro dysfunc. that resolves spontaneously

68
Q

Typical mechanism for concussion?

A

coup (blow) coutre-coup (counter blow)

69
Q

S/S of concussion?

A

+/- LOC (usually none)

confusion

memory loss

visual disturbance

vertigo/impaired balance

HA

70
Q

Post concussive sxs?

A

Chronic HA

Short-term memory difficulties

Fatigue

Difficulty sleeping

Personality changes (irritability, mood swings)

Sensitivity to light/noise

(Symptoms typically resolve in days to months)

71
Q

How do we dx a concussion?

A

clinically!

Head CT usually NOT recommended
-do neuroimaging if LOC or GCS <15

new lab testing: brain trauma indicator- measures levels of proteins UCH-L1 and GFAP

72
Q

Concussion tx?

A

rest and acetaminophen for HA

73
Q

When can pts return to play after concussion?

A

not until all sxs are gone and no meds are required

74
Q

What is an epidural hematoma?

A

accumulation of blood in the potential space btwn dura and bone

intracranial EDH require immediate surgical intervention

75
Q

pathophys of EDH

A

results from linear contact force to skull that causes seperation of periosteal dura from bone w/ disruption of the vessels btwn due to shearing stress

76
Q

What are some causes of EDH?

A

trauma, LP,, anticoagulation, cancer, vascular malformation, disk herniation, valsalva maneuver, etc.

77
Q

EDH presentation?

A

suspect in any head trauma

sxs: ALOC, HA, N/V, seizures, focal neuro deficits

spinal EDH: weakness, sensory deficits, alteration in reflexes, alteration in bladder or anal sphincter tone

78
Q

EDH physical exam?

A

eval for:

  • skull fx, hematoma
  • raccoon eyes or battle sign- thick basilar fx -hemotypanum
  • GCS
  • decerebrate and decorticate posturing
  • weakness
  • oculocephalic reflex (Doll’s eyes)
  • anisocoria
79
Q

What are the 3 areas evaluated in a GCS score?

A

eye opening

verbal

motor

80
Q

What are some common CNS herniations? Presentations?

A

Subfalcine: HA contralateral leg weakness.

Transtentorial: oculomotor (CN III) paresis (ipsilateral dilated pupil, abnl EOM’s), contralateral hemiparesis.

Tonsillar: Obtundation

81
Q

A brain herniation is…

A

life threatening!

increased ICP may cause cushing’s syndrome

82
Q

Work up for EDH?

A

CBC

coags

serum chemistry

toxicology screen

type and screen

Imaging: skull xray, CT MRI, myelography

83
Q

What does an EDH look like on CT?

A

whitened area on edge of skull

“white ain’t right”

looks like lemon

84
Q

EDH tx?

A

emergency decompression with placement of burr hole to decrease ICP if neurosurg is not immediately available

Surg: crainotomy or laminectomy > evacuation of hemotoma

elevate head of bed at 30 deg

+/- coagulopathy: fresh frozen plasma, K+

Osmotic diuretics- for those with elevated ICP

Acetaminophen for fever

Anticonvulsants as propylaxis

85
Q

Where should a burr hole be placed for pts that demonstrate signs of rapid decompensation?

A

on the side of the dilating pupil

86
Q

What can you give to spinal epidural pts when cord is compressed?

A

high dose methylprednisolone

87
Q

What is a subdural hematoma?

A

Collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane

MC type of traumatic intracranial mass lesion

can be acute, subacute or chronic

88
Q

Usual mechanism for subdural hematoma?

A

coup/contra-coup injury to brain

small subdurals will resorb spontaneously

89
Q

subdural hematoma presentation?

A

acute: varies, pts often comatose

Chronic: usually insidious and in those > 40 y/o

sxs: ALOC, HA, dif. w/ gait, cognitive dysfunc, personality change

90
Q

Work up for subdural hematoma?

A

Emergent non con CT head

consult neurosurg

blood work

91
Q

When should you repeat imaging in suspected SDH?

A

if GCS worsens by 2 or more points

92
Q

Tx for acute SDH?

A

ABCs

osmotic diuretics

surg decompression

admit to ICU

Foundations II-Neurology (9 decks)

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