13. Confusion

Question 1

Confusion defn per ch 13

Answer 1

acute impairment in higher cerebral function (memory attention, awareness)

Question 2

4 major groups of disorders in confusion

Answer 2

CNS
primary IC disease
exogenous toxin
drug withdrawal state

Question 3

Critical causes of confusion: name 4

Answer 3

hypoxia
hypoventilation
hypoglycemia
delirium tremens

Question 4

Emergent IC disease causes of confusion

Answer 4

seizure/NCSE
tbi
htn encephalopathy

Question 5

Emergent systemic disease secondary effecting CNS - disease causes of confusion

Answer 5

sepsis
hepatic encephalopathy
uremia/renal failure
hyperthermia/hypo
endocrinopathy
nutritional deficiency

Question 6

Emergent exogenous toxin causes of confusion

Answer 6

sedative/hallucination
etoh/toxic etoh
narcotis
antihistamine

Question 7

Emergent drug w/d causes of confusion

Answer 7

etoh
drug of abuse

Question 8

What is the aeiou mneumonic for altered mental status?

Answer 8

etoh/drug intox; atypical migraine
electrolytes, environment (hypot/hyper), endocrinopathy, encephalopathy (wernicke), epilepsy
infection - mening/enceph, sepsis
OD, o2 (hypoxia, PE)
uremia
trauma, tumor
insulin (hypoglycemia, dka, hhs)
poison, psychosis
stroke, status epilepticus

Question 9

Key historical q/information helping with ddx confusion

Answer 9

new meds
infection sx
hx haed trauma
hx seizure
migraine hx
time course onset

Question 10

Key PE findings to pinpoint confusion cause

Answer 10

Vitals
trauma
focal neuro deficit
loss attention
preservation orientation
toxidrome

Question 11

Delirium vs psych vs dementia: history findings

Answer 11

acute onset
onset week-mo, age 12-40
onset over mo, usually >65

Question 12

Delirium vs psych vs dementia: MSE

Answer 12

fluctuate, disorient, attention disturbances, hallucinations - vis/tactile, cognition changes

alert, oriented, agit/anxious, hallucin-auditory, delusions, illusions

alert, disoriented, memory impaired,absent halluc unless lewy body, word finding difficulties

Question 13

Delirium vs psych vs dementia: PE

Answer 13

abnormal vitals, nystagmus, focal neuro signs, signs trauma

N vitals, no nystagmus, purporseful movement, no signs trauma

N VS, neuro deficits in vascular dementia, can show parkinsonism, no sign trauma

Question 14

Delirium triage screen - what is this include?

Answer 14

Altered conscioussness via RASS: if RASS not zero - DTS + conifrm with bCAM

if RASS 0 –> spell LUNCH bwd to assess inattention: if >1 eror –> bcam vs 0/1 error - dts neg no delirium

Question 15

Brief Confusion Assessment Method: bCAM components:

Answer 15

1. AMS or fluctuating course? –no = no delirum
   if y
2. inattention - mo bwd dec to july –> 0-1 error = no delir
   if y/ >1 error
3. RASS assessment –> y = no delirium
   if no:
4. diroganized thinking/q –> no errors no delirium
   - q: are there fish in the sea? How many fingers is this (hold 2) - now do the same thing with your hand

Question 16

The confused pt: general basic w/u

Answer 16

1. vitals
2. glucose
3. DTS, bCAM
4. sp testing based on hx exam
   - trauma: ct
   - infection: cultures, cxr, urine –> abx/IVF
   - drug/med effect: antidote or supportive care, stop offending
   - other: endocrine: tsh/panel, nutr defic: b12/tsh/etc, NSCE - eeg, urea if HE concern, toxin panel

Question 17

Wernicke concern - dose thiamine?

Answer 17

at least 100mg IV

Question 18

Hypoglycemia tx

Answer 18

D50 amp of 5ml in 50% dextrose
or
250ml of 10% dextrose

Question 19

If agitated, safe meds for pt?

Answer 19

haldol 1-5mg IV repeat q15 min IV or q30 min IV up tp max 10-20mg/d

Question 20

Adverse effects haldol

Answer 20

QT prolongation
acute dystonic reaction
tardive dyskinesia

Question 21

Which pt population cannot have haldol?

Answer 21

Parkinson’s - incr risk death

Question 22

Common ways to help confusion with supportive care

Answer 22

1:1 sitter
quiet environment
family present if possible
avoid restraints

Question 23

1. A 70-year-old man with a chief complaint of confusion is brought to the emergency department by his family. Which of the following initial assessments should be included?
   a. Bloodpressure
   b. Pulse oximetry c. Temperature d. All of these

Answer 23

d

Question 24

A variety of brief screening tools may aid in the detection of confu- sion. All of these tests focus on which cardinal finding of confusion? a. Attentionimpairment
b. Decreased level of arousal
c. Disorientation
d. Long-term memory impairment

Answer 24

a

Question 25

A 30-year-old patient is brought to the emergency department for
evaluation of odd behavior. Which of the following characteristics might suggest a psychiatric cause for the behavior?
a. Auditoryhallucinations
b. Disorientation
c. Fever
d. Visual hallucinations

Answer 25

a

Question 27

Postictal confusion is common in patients with seizures, but if improvement in consciousness does not occur within 20 to 30 minutes after seizure cessation, which of the following conditions should be considered?
a. Electrolyteabnormalities
b. Hypoglycemia
c. Nonconvulsive or subtle status epilepticus d. All of these

Answer 27

d