CN LANGE - Confusional States I Flashcards Preview

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Flashcards in CN LANGE - Confusional States I Deck (93):
1

The difference between a confusional state and coma is largely one of ...?

DEGREE - The causes overlap extensively.

2

Evaluation of a patient with altered consciousness is aimed:

1. Characterize the nature of the disorder (confusional state, coma, or a more chronic condition, such as dementia).
2. Determine the cause.

3

A confusional state is most readily distinguished from dementia by the ...?

TIME COURSE of impairment.
--> Confusional states are acute or subacute in onset, typically developing over hours to days, whereas dementia is a chronic disorder that evolves over months to days.

4

Certain causes of confusional state must be identified urgently because they may lead rapidly to severe structural brain damage or death, which prompt treatment can prevent. Give some examples:

1. Hypoglycemia.
2. Bacterial meningitis.
3. SAH.
4. Traumatic intracranial hemorrhage.
5. Wernicke encephalopathy.

5

Hypoglycemia - Clinical evidence:

1. Tachycardia.
2. Sweating.
3. Dilated pupils.
4. Sometimes progressing to mimic herniation.
5. With or without lateralized signs.
--> Give IV glucose.

6

Bacterial meningitis - Clinical evidence:

1. Headache.
2. Fever.
3. Brudzinski or Kernig sign.

7

SAH - Clinical evidence:

1. Headache.
2. HTN.
3. Retinal hemorrhages.
4. Brudzinski or Kernig sign.

8

Traumatic intracranial hemorrhage - Clinical evidence:

1. Headache.
2. HTN.
3. Lateralized neurologic signs.

9

Wernicke encephalopathy - Clinical evidence:

1. Ophthalmoplegia.
2. Ataxia.

10

Preexisting conditions that predispose to confusional states should be noted:

1. Alcoholism (intoxication or withdrawal, or Wernicke encephalopathy).
2. Drug abuse (intoxication or infection.
3. Diabetes (hypo- or hyperglycemia).
4. Heart disease (stroke).
5. Epilepsy (seizures or postictal state).
6. Head trauma (concussion, intracranial hemorrhage).
7. Thorough medication history.

11

General physical exam in confusional states - Fever - Most suggestive of:

1. Meningitis.
2. Anticholinergic or SNS intoxication.
3. Ethanol or sedative drug withdrawal.
4. Sepsis.

12

General physical exam in confusional states - Hypothermia - Most suggestive of:

1. Ethanol or sedative drug intoxication.
2. Hepatic encephalopathy.
3. Hypoglycemia.
4. Hypothyroidism.
5. Sepsis.

13

General physical exam in confusional states - HTN - Most suggestive of:

1. Anticholinergic or SNS intoxication.
2. Ethanol or sedative drug withdrawal.
3. HTN encephalopathy.
4. SAH.

14

General physical exam in confusional states - Tachycardia - Most suggestive of:

1. Anticholinergic or SNS intoxication.
2. Ethanol or sedative drug withdrawal.
3. Thyrotoxicosis.
4. Sepsis.

15

General physical exam in confusional states - Bradycardia - Most suggestive of:

Hypothyroidism.

16

General physical exam in confusional states - Hyperventilation - Most suggestive of:

1. Hepatic encephalopathy.
2. Hyperglycemia.
3. Sepsis.

17

General physical exam in confusional states - Neck stiffness - Most suggestive of:

1. Meningitis.
2. SAH.

18

General physical exam in confusional states - Battle sign or raccoon eyes - Most suggestive of:

Head trauma.

19

General physical exam in confusional states - Hemotympanum - Most suggestive of:

Head trauma.

20

General physical exam in confusional states - CSF oto- or rhinorrhea - Most suggestive of:

Head trauma.

21

General physical exam in confusional states - Jaundice - Most suggestive of:

Hepatic encephalopathy.

22

General physical exam in confusional states - Petechial rash - Most suggestive of:

Meningococcal meningitis.

23

General physical exam in confusional states - Heart murmur - Most suggestive of:

1. Infection.
2. Stroke.

24

General physical exam in confusional states - Abdominal mass - Most suggestive of:

1. Infection.
2. Tumor.
3. Hepatic encephalopathy.

25

General physical exam in confusional states - Rectal bleeding - Most suggestive of:

Hepatic encephalopathy.

26

Neurologic exam - Mental status exam - Should focus on confirming that the level of consciousness is depressed by evaluating the following functions:

1. Wakefulness.
2. Arousability.
3. Orientation.
4. Attention.
5. Memory.

27

Wakefulness:

In confusional states, the patient often appears sleepy - This may alternate with apparent alertness.

28

Neurologic examination in confusional states - Papilledema - Most suggestive of:

1. HTN encephalopathy.
2. Intracranial mass.

29

Neurologic examination in confusional states - Dilated pupils - Most suggestive of:

1. Head trauma.
2. Anticholinergic intoxication.
3. Withdrawal from ethanol or sedative drugs.
4. SNS intoxication.

30

Neurologic examination in confusional states - Constricted pupils - Most suggestive of:

Opioid intoxication.

31

Neurologic examination in confusional states - Nystagmus or ophthalmoplegia - Most suggestive of:

1. Ethanol intoxication.
2. Sedative drugs, or PCP.
3. Vertebrobasilar ischemia.
4. Wernicke encephalopathy.

32

Neurologic examination in confusional states - Tremor - Most suggestive of:

1. Withdrawal from ethanol or sedative drugs.
2. SNS intoxication.
3. Thyrotoxicosis.

33

Neurologic examination in confusional states - Asterixis - Most suggestive of:

Metabolic encephalopathy.

34

Neurologic examination in confusional states - Hemiparesis - Most suggestive of:

1. Stroke.
2. Head trauma.
3. Hyper/hypoglycemia.

35

Neurologic examination in confusional states - Ataxia (especially gait) - Most suggestive of:

1. Ethanol or sedative drug intoxication.
2. Wernicke encephalopathy.
3. Vertebrobasilar ischemia.

36

Neurologic examination in confusional states - Seizures - Most suggestive of:

1. Ethanol or sedative drug withdrawal.
2. Hypo/hyperglycemia.
3. Head trauma.

37

One pitfall to avoid is to mistake ... for confusion.

Wernicke aphasia for confusion.
--> Patients with aphasia appear normally awake and alert, can respond appropriately to non verbal commands (such as gestures) + usually have associated right-sided neurologic abnormalities such as hemiparesis, hemisensory deficit, and visual field deficits.

38

Signs of diffuse vs focal disorders causing confusional states - Diffuse disorders - Suggestive findings:

1. Fever or hypothermia.
2. Nystagmus.
3. Tremor.
4. Asterixis.
5. Myoclonus.

39

Signs of diffuse vs focal disorders causing confusional states - Focal disorders - Suggestive findings:

1. Head trauma.
2. Papilledema.
3. Hemiparesis.
4. Focal seizures.
5. Asymmetric hyperreflexia.
6. Unilateral Babinski signs.

40

Laboratory studies in confusional states - WBC increased - Most suggestive of:

1. Meningitis.
2. Encephalitis.
3. Sepsis.

41

Laboratory studies in confusional states - PT and PTT increased - Most suggestive of:

Hepatic encephalopathy.

42

Laboratory studies in confusional states - Arterial blood gases - Metabolic acidosis - Most suggestive of:

1. DKA.
2. Lactic acidosis (postictal, shock, sepsis).
3. Toxins (methanol, ethylene glycol, salicylates, paraldehyde).
4. Uremia.

43

Laboratory studies in confusional states - ABG - Respiratory acidosis - Most suggestive of:

1. Pulm. insufficiency.
2. Sedative drug OD.

44

Laboratory studies in confusional states - ABG - Respiratory alkalosis - Most suggestive of:

1. Hepatic encephalopathy.
2. Pulm. insufficiency.
3. Salicylates.
4. Sepsis.

45

Laboratory studies in confusional states - Osmolarity increased - Most suggestive of:

1. Hyperglycemia.
2. Alcohol intoxication.

46

Laboratory studies in confusional states - EEG - Epileptiform activity - Most suggestive of:

1. Complex partial seizures.
2. Postictal state.

47

Laboratory studies in confusional states - Periodic complexes - Most suggestive of:

HSV encephalitis.

48

Ethanol intoxication produces a confusional state with:

1. Nystagmus.
2. Dysarthria.
3. Limb and gait ataxia.

49

Serum osmolarity exceeds the calculated osmolarity by ... for every 100mg/dL of alcohol.

22mOsm/L for every 100mg/dL.

50

Chronic alcoholism also increases the risk of ...?

Bacterial meningitis.

51

Alcohol withdrawal - 3 common withdrawal syndromes are recognized:

1. Tremulousness and hallucinations.
2. Seizures.
3. Delirium tremens.

52

Tremulousness and hallucinations:

Self-limited condition occurs within 2 DAYS after cessation of drinking and is characterized by:
1. Tremulousness.
2. Agitation.
3. Anorexia.
4. Nausea.
5. Insomnia.
6. Tachycardia.
7. HTN.
--> Confusion, if present, is mild.
25% --> Illusions and hallucinations, usually visual, occur in approx. 25% of patients.

53

Alcohol withdrawal seizures occur within ...?

48HOURS of abstinence and within 7 to 24h in approx. 2/3 of cases.

54

Alcohol withdrawal seizures - How many?

1. Roughly 40% of patients who experience seizures have a single seizure.
2. More than 90% have between 1-6 seizures.

55

Alcohol withdrawal seizures - In approx. ...% of cases, the interval between the first and last seizures is 6hours or less.

85%.

56

The most serious ethanol withdrawal syndrome typically begins ...?

3-5 days after cessation of drinking and lasts for up to 72h.
--> DELIRIUM TREMENS.

57

Delirium tremens is characterized by:

1. Confusion.
2. Agitation.
3. Fever.
4. Sweating.
5. Tachycardia.
6. HTN.
7. Hallucinations.

58

Delirium tremens - Death may result from ...?

1. Concomitant infection.
2. Pancreatitis.
3. Cardiovascular collapse.
4. Trauma.

59

Sedative drug intoxication - The classic signs are:

1. Confusional state or coma.
2. Respiratory depression.
3. Hypotension.
4. Hypothermia.
5. Reactive pupils.
6. Nystagmus or absent ocular movements.
7. Ataxia.
8. Dysarthria.
9. Hyporeflexia.

60

Glutethimide or very high doses of barbiturates may produce:

1. Large, fixed pupils.
2. Decerebrate or decorticate posturing can occur in sedative drug-induced coma.

61

Sedative drug ingestion can be confirmed by ...?

Toxicologic analysis of blood, urine, or gastric aspirate, but blood levels of short-acting sedatives do NOT correlate with clinical severity.

62

Complications of sedative drug intoxication:

1. Aspiration pneumonia.
2. Hypotension.
3. Renal failure.

63

Sedative drug withdrawal can produce:

1. Confusional states.
2. Seizures.
3. Syndrome resembling delirium tremens.

64

Withdrawal syndromes typically develop ... after cessation of SHORT-acting sedatives.

1 to 3 days.
--> But may not appear until 1 week or more with LONGER-acting drugs.

65

Sympathomimetic intoxication can produce:

A confusional state with:
1. Hallucinations.
2. Motor hyperreactivity.
3. Stereotypic behavior.
4. Paranoid psychosis.

66

Hallucinogens include:

1. Lysergide acid diethylamide (LSD).
2. Psilocybin.
3. Mescaline.
4. PCP.
5. Ketamine.
6. Ibogaine.
7. Bufotenin.

67

Features of PCP intoxication include:

1. Drowsiness.
2. Agitation.
3. Disorientation.
4. Amnesia.
5. Hallucinations.
6. Paranoia.
7. Violent behavior.

68

PCP intoxication - Neurologic exam may show:

1. Large or small pupils.
2. Horizontal and vertical nystagmus.
3. Ataxia.
4. Incr. muscle tone.
5. Analgesia.
6. Hyperreflexia.
7. Myoclonus.

69

PCP intoxication - In severe cases - Complications include:

1. HTN.
2. Malignant hyperthermia.
3. Status epilepticus.
4. Coma.
5. Death.

70

Hypothyroidism - CSF:

CSF protein is typically elevated.
+ CSF pressure is occasionally increased.

71

Thyrotoxicosis in young and old patients:

In younger patients --> Agitation, hallucinations, and psychosis are common.
In older patients (>50) --> Apathetic and depressed (apathetic thyrotoxic crisis).

72

Hypoglycemia - Etiology:

1. Insulin OD (MCC in diabetics).
2. Oral hypoglycemic drugs.
3. Alcoholism.
4. Malnutrition.
5. Hepatic failure.
6. Insulinoma.
7. Non-insulin-secreting fibromas.
8. Sarcomas/fibrosarcomas.

73

Hypoglycemia - How does the neurologic dysfunction progress?

In a rostral-caudal fashion + may mimic a mass lesion causing transtentorial herniation.

74

Hypoglycemia - Coma ensues with ...?

1. Spasticity.
2. Extensor plantar responses.
3. Decorticate or decerebrate posturing.

75

Hyperglycemia - The severity of hyperosmolarity or the degree of systemic acidosis correlates well with depression of consciousness?

The SEVERITY OF HYPEROSMOLARITY.

76

Treatment of DKA:

1. IV isotonic saline.
2. Regular insulin.
3. Potassium.
4. Antibiotics are added for concomitant infections.

77

DKA - Deaths are usually related to:

1. Sepsis.
2. Cardiovascular or cerebrovascular complications.
3. Renal failure.

78

Hyperosmolar nonketotic hyperglycemia - Treatment:

1. Fluid replacement with 0.45% saline, EXCEPT for patients with circulatory collapse --> Normal saline.
2. Potassium + if indicated Phosphate should be replaced.
3. Less insulin is required than for DKA.

79

Hyperosmolar nonketotic hyperglycemia - When death occurs, it is usually caused by?

Coexisting disease or delayed treatment due to misdiagnosis.

80

Hypoadrenalism - Neurologic manifestations include:

1. Confusional states.
2. Seizures.
3. Coma.

81

Hypoadrenalism - Treatment:

1. Administration of hydrocortisone.
2. Correction of hypovolemia, hypoglycemia, electrolyte disturbances + precipitating illnesses.

82

Hyperadrenalism - Neuropsychiatric disturbances are common and include:

1. Depression or euphoria.
2. Anxiety.
3. Irritability.
4. Memory impairment.
5. Psychosis.
6. Delusions.
7. Hallucinations.

83

Hyponatremia produces:

1. Headache.
2. Lethargy.
3. Confusion.
4. Weakness.
5. Muscle cramps.
6. Nausea.
7. Vomiting.

84

Hyponatremia - Neurologic signs include:

1. Confusional state or coma.
2. Papilledema.
3. Tremor.
4. Asterixis.
5. Rigidity.
6. Extensor plantar responses.
7. Focal or generalized seizures.
8. Occasionally focal neurologic deficits.

85

Hyponatremia - Immediate management includes:

1. Water restriction.
2. Infusion of hypertonic saline +/- furosemide (for severe symptoms).

86

Excessively rapid correction of hyponatremia may lead to ...?

OSMOTIC DEMYELINATION SYNDROME (formerly designated central pontine myelinolysis).

87

Osmotic demyelination syndrome - Characterized by:

1. Confusional state.
2. Paraparesis or quadriparesis.
3. Dysarthria.
4. Dysphagia.
5. Hyper- or hyporeflexia.
6. Extensor plantar responses.
--> Severe cases can result in the locked-in syndrome.

88

Rate of correction of hyponatremia:

4 to 6 mmol/L/Day.

89

Hypercalcemia - Neurologic symptoms are always present with serum calcium levels higher than ...?

17mg/dL (8.5mEq/L) and include:
1. Headache.
2. Weakness.
3. Lethargy.

90

Hypercalcemia - Physical exam may show:

1. Dehydration.
2. Abdominal distention.
3. Focal neurologic signs.
4. Myopathic weakness.
5. Confusional state that may progress to coma.

91

Hypercalcemia - The myopathy spares ...?

Bulbar muscles + tendon reflexes are usually normal.

92

Hypocalcemia - Symptoms:

1. Irritability.
2. Delirium.
3. Psychosis with hallucinations.
4. Depression.
5. Nausea/vomiting.
6. Abdominal pain.
7. Paresthesias of the circumoral region + distal extremities.

93

Confusional state:

Sometimes referred to as encephalopathy or delirium, is a state in which the level of consciousness is depressed, but to a lesser extent than in coma (unarousable unresponsiveness).