Flashcards in ECEs: Neck up, peripheral, & systemic Deck (143)
What is altered mental status?
Decrease in LOC
What is the DDx for altered mental status (overal mnemonic)?
What are some drug-related causes of altered mental status? (4 categories; name at least 1 example of each)
Abuse (opiates, benzos, alcohol, illicit drugs)
Accidental (carbon monoxide, cyanide)
Prescribed (Beta-blockers, TCAs, ASA, acetaminophen, digoxin)
Withdrawal (Benzos, EtOH, SSRIs)
What are some infectious causes of altered mental status? (2 categories, 3 examples each)
CNS: meningitis, encephalitis, cerebral abscess
Systemic: sepsis, UTI, pneumonia, skin/soft tissue, bone/joint, intra-abdominal, iatrogenic (indwelling lines or catheter), bacteremia
What are some metabolic causes of altered mental status? (4 categories, 1 example each)
Kidneys: electrolyte imbalance, renal failure, uremia
Liver: hepatic encephalopathy
Pancreas: hypoglycemia, DKA, HHS
Thyroid: hyper or hypo
What are some structural causes of altered mental status? (3 categories, 2 examples each)
Cardiac: ACS, dissection, arrythmias, shock
Brain: Stroke, Sz, hydrocephalus, surgical lesions
Bleeds: any ICH -- epidural hematoma, subdural hematoma, SAH; acute or chronic
What are important components of the history in altered mental status?
Collateral from family/friends/EMS
Comparison to baseline
What are important components of the initial/acute physical exam in altered mental status?
Standard rapid assessment:
ABCs, primary survey
vitals including temp & glucose
rapid neuro exam (GCS, focal deficits)
What labs would you order for altered mental status?
CBC, lytes, BUN/Cr, LFTs, INR/PTT, serum osmolality, VBG, troponin, urinalysis, drug levels
What tests (non-BW) would you order for altered mental status?
ECG, CXR, CT head
How do you acutely manage altered mental status, in general?
Supportive + Treat underlying cause
Broad spectrum Abx
Warm/cool, BP control
Consider admitting for workup
What are the universal antidotes?
dextrose, oxygen, naloxone, thiamine
What are the 3 most common primary types of headache?
Migraine, Cluster, and Tension
What is the typical presentation of migraine?
POUND: Pulsatile, Onset 4-72h, Unilateral, N/V, Disabling
photo/phonophobia, recurrent, +/- aura
What is the typical presentation of cluster headaches?
Unilateral sudden sharp retro-orbital pain
Usually at night
Autonomic: congestion, rhinorrhea, lacrimation, facial flushing
pseudo-Horner's syndrome (ptosis, miosis, anhidrosis, and hyperemia)
precipitated by EtOH, smoking
What is the typical presentation of tension headache?
tight band-like pain, tense neck/scalp muscles, precipitated by stress or lack of sleep
What is the intracranial DDx for headache?
Bleed: epidural, subdural, subarachnoid, intracerebral
Infection: meningitis, encephalitis, brain abscess
Increased ICP: mass, cerebral venous sinus thrombosis
What is the extracranial DDx for headache?
Acute angle closure glaucoma
Carotid artery dissection
What are red flags for headache?
Altered mental status
What are the symptoms of increased ICP?
headache worse lying down and in the morning
What components of the physical exam are important for assessing headache?
Vitals, detailed neuro exam
Neck flexion for meningeal irritation
Eye exam (slit lamp, IOP)
Temporal artery tenderness
What investigations should be done for headache?
Most benign headaches do not require further investigation.
Neuroimaging based on Ottawa SAH rule.
LP: if CT head -ve, but suspicion of SAH
ESR/CRP if ?temporal arteritis
What is the Ottawa SAH Rule?
Decision rule to rule out SAH.
Use in: Alert patients ≥15 years old, new severe atraumatic headache, maximum intensity within 1 hour.
If any of the following features, SAH cannot be ruled out:
- Neck pain or stiffness
- Witnessed LOC
- Onset during exertion
- Thunderclap headache (instantly peaking pain)
- Limited neck flexion on exam
How do you manage benign headaches in the ED?
Fluids: no clear evidence, but consider if dehydrated
Antidopaminergic agent: Metoclopramide 10mg IV
Analgesic: Acetaminophen 1g po
NSAIDs: Ketorolac 15-30mg IV or Ibuprofen 600mg po
Steroids: Dexamethasone 10mg po/IV (rebound migraine prophylaxis)
What is the current (2016) definition of sepsis?
Life-threatening organ dysfunction caused by dysregulated response to infection
What is SIRS? What are the criteria?
Systemic Inflammatory Response Syndrome
2 or more of:
T < 36 or > 38.3
HR > 90
RR > 20 or CO2 < 32
WBC < 4 or > 12
What history is important for sepsis?
(Trying to ID a focus)
What physical exam components are important for workup of sepsis?
Look for a focus
What is the full septic workup? (Labs and other tests)
CBC, lytes, extended lytes
Tests: ECG, CXR