AMS prelecture

Question 1

What are the two things that define mental status

Answer 1

Emotional and intellectual functioning

Ch. 129 (hypoglycemia/DKA only), 141, 142

Question 2

What is confusion

Answer 2

Unusual for INDIVIDUAL or DEVIATEs from social norms

-often uncooperative/

Question 3

If diminished LOC, what are your differentials?

Answer 3

Coma/stupor

Question 4

If you have (+) focal neuro deficits, what are you thinking?

Answer 4

Brain structure

Stroke/mass lesion

Question 5

When do you perform a MMS exam?

Answer 5

If altered behavior in a patient who is awake, alert without neuro deficit, perform MMS exam to differentiate confusion and delirium from a psychiatric disorders

Question 6

If a patient has an abnormal MMS exam, what are you thinking? Normal?

Answer 6

Abnormal = confusion/delirium
Normal = Thought disorder/ psych disorder

Question 7

Initial evaluation for a patient with AMS and what ALL patients get

Answer 7

ABCDEs

1. Vital signs
2. POC glucose
3. If shock IV NS/LR bolus
4. Hypoxic = order ABG b4 O2 if possible to check results, 1-4 NC (if more, only for a few hours, but higher flow is preferred) VBG if just worried about pH
5. Correct respiratory failure
6. IV access with 2 large bore needles (18 or 20 gauge so that you can push fluids rapidly)
7. Administer coma cocktail (dextrose if hypoglcemic, thiamine, Narcan - should show improvement in like 5 min max)

Question 8

why do you give thiamine for an AMS patient? When do you give it in the cocktail

Answer 8

Wernicke encephalopathy from alcohol OD is helped by thiamine, and thiamine helps with cellular respiration, so give BEFORE or DURING glucose (not after).

Question 9

A patient has an abrupt AMS, what are your ddx?

Answer 9

iscehmia
SAH
Seizure

Question 10

A patient has a rapid, but not abrupt AMS, what are your ddx?

Answer 10

delrium

acute remember

Question 11

A patient has a gradual AMS, what are your ddx?

Answer 11

space occupying lesion
dementia
psych disorders

Question 12

A patient has a fluctuating AMS, what are your ddx?

Answer 12

seizures
stroke
delirium

Question 13

You patient has a history of chronic alcohol use or chornic malnutrition, what is your ddx?

Answer 13

Wernicke’s encephalopathy

Question 14

How might a history of auditory vs visual hallucination change your ddx?

Answer 14

auditory = more likely to be psych
visual = more likely to be medically related

Question 15

What are common medical causes of AMS?

Answer 15

1. Comorbid conditions
2. med changes
3. late age onset
4. sudden in onset and fluctuate over hours/ days (thinking about the med being excreted)

Question 16

what do non-reactive pupils suggest?

Answer 16

upper brainstem lesion (close to the eye nerves)?

Question 17

dolls eyes test normal sign and when to use it

Answer 17

eyes move opposite direction of head (still fixing gaze)

shows EOM are in tact

used only when C spine is cleared

Question 18

nystagmus testing and when to use it

Answer 18

Use when C-spine is NOT cleared

COWS

cold opposite warm same (normal)

Question 19

GCS scoring

Answer 19

If 8, intubate

EYES
VOICE
OLD BEN

Eyes shut
“Y” did you hurt me
Ear piercing noise
Spontaneous

Voiceless
Obscure
Inapprapropiate
Confused
Elegant

Obey comands
Localizes to pain
Draw away
Bends (decoriatate)
Extends (deceberate)
No response

Question 20

How do you observe consciousness in kids?

Answer 20

Based on how they are moving/interacting with people

Cannot do EOM, just look for eye movement

Question 21

What can you use to assess confusion quickly in adults?

Answer 21

Six item screener

3 item memory recall (after 3-5 min)

Year, month, day of week (easier to know that then day of month)

Question 22

Apart from hallucinations, what is another way to differentiate medical/neurological from psych disorders

Answer 22

Disorientation and memory indicate medical/neuro, while disorders of thought content suggest psych

Question 23

How to rule out cardiac causes of AMS? Hypoxic?

Answer 23

EKG
CXR

Question 24

When do you get a head CT for LOC? is it w/ or w/out contrast

Answer 24

Head CT - without contrast
if focal neurologic signs, papilledema or FEVER

Question 25

When to get an LP with CSF analysis for AMS

Answer 25

CNS infection, SAH not seen on CT Relative CI - cerebral edema, increased ICP

Question 26

When do you get an EEG?

Answer 26

consider if no other source of AMS if found or if underlying seizure disorder

Question 27

treatment of delirium/dementia and the SE of the meds

Answer 27

Underlying illness Haldol (EPS and QT prolongation) Lorazepam (respiratory depression) For delirium, admit unless cause is identified, treatment is initiated, and improvement is seen For dementia, admit unless patient has long-standing stable symptoms, consistent caregivers and reliable follow up for outpatient evaluation

Question 28

What is delerium vs dementia?

Answer 28

Delerium = acute change in attention and mental function (over a 24 hour period) and cognition, often with sleep-wake cycles disrupted (tired at day or night) dementia = slow onset of chronic cognitive dysfunction in one + cognitive domains. Attention is NORMAL.

Question 29

A patient presents to your office after OD and narcan is adminstered and the patient is stable - how do you manage?

Answer 29

Observe for 60-90 minutes then discharge based on 1) intential = suicide attempt 2) accidental = psych

Question 30

What is hypoglycemia in kiddos?

Answer 30

< 45 with symptoms < 35 asymptomatic

Question 31

What is the mangement of hypoglycemia in kids?

Answer 31

1. Juice 2. Dextrose (D10W for neonates, D25W for kids; maintenance with DW10 for both) 3. Glucagon (opposes insulin) admit all kids requiring resuscitation

Question 32

What is hypoglycemia in adults? Mng?

Answer 32

< 70? 1. D50W 2. POC glucose every 30 min for 2 hours 3. Continuous D10W maintenance (same as kiddos) 4. IM Glucagon only if unable to establish IV 4. Octerotide if refractory hypoglycemia related to sulfonyurea use (-ides)

Question 33

t/f if a patient has an insulin pump and is hypoglycemic, immediately remove the insulin pump so that they do not go further into hypoglycemia

Answer 33

FALSE - may go into DKA consult endocrine after to lower pump basal rate

Question 34

When to admit or discharge hypoglycemic patients

Answer 34

Admit if on long-acting hypoglycemic drugs (for serial glucose monitoring) If discharge educate to continue carbohydrate intake and monitor glucose

Question 35

5 functions of insulin

Answer 35

1. drives glucose into cells 2. drives K+ into cells 3. creates an anabolic environment (because there is enough sugar for energy, so you do not need to break down other energy stores) 4. inhibits breakdown of fat (because you can use glucose) 5. blocks the breakdown of proteins (because you can use glucose)

Question 36

What is DKA and is it MC in T1 or T2?

Answer 36

A life-threatening complication of DM that occurs as a result of significant INSULIN DEFICIENCY resulting in HYPERGLYCEMIA and ketoacidosis. MC in T1 as it is an insulin-dependent DM Often the first sign of T1DM in a kiddo

Question 37

6 I's of the etiologies DKA

Answer 37

infection infarction insult (to the body) impregnated indiscretion (lack of care) insulin (absence)

Question 38

s/s of DKA and 3 key features

Answer 38

think of DM on steroids 1. hyperglycemia symptoms 2. volume depletion symptoms 3. Acidosis symptoms Polydypsia/uria (1st symptoms) Volume depletion symptoms (because your body is trying to get rid of sugar, drawing fluids outside of the body) Acidosis (tachypnea, kussmaul respiration [fast deep breathing], fruity breath - all of this is because the body tries to blow off CO2)

Question 39

pathophys of DKA

Answer 39

1. Glucose does not enter the cell 2. Liver creates more glucose because the cells are not getting glucose 3. Breakdown of fat and muscle for energy (leads to weight loss) leading to ketones that can enter the brain 4. Ketones build up leading to acidosis 5. Kidneys compensate by trying to pee it all out 6. Leads to dehydration and vomiting leads to more dehydration

Question 40

diagnostics of DKA

Answer 40

POC glucose Phos + Mg ABG UA SERUM ketones (most important) EKG (MI and hyperkalemia)

Question 41

diagnostic criteria for DKA

Answer 41

Blood glucose level >250 mg/dL Anion gap >10 to 12 mEq/L¹ Bicarbonate level <15 mEq/L pH <7.3 with moderate ketonuria or ketonemia does NOT need to be > 250 if: 1. shortly after insulin T1 young and vomitting alcohol abuse/ liver failure Low caloric intake Depression Preggo SGLT2 inhibitors

Question 42

Overall management of DKA

Answer 42

Volume repletion Reverse insulin insuffiency Correct electrolytes and acid/base Treat cause Avoid complications

Question 43

Volume resuscitation for DKA

Answer 43

2 large IV bolus with NS followed by 1/2 NS TKO (to keep open the vein) 1/2 NS @ 250-500 per hour if normal or elevated Na - if hyponatremic keep NS Need to know 15-20 mL/kg/h