13. Confusion Flashcards
Confusion defn per ch 13
acute impairment in higher cerebral function (memory attention, awareness)
4 major groups of disorders in confusion
CNS
primary IC disease
exogenous toxin
drug withdrawal state
Critical causes of confusion: name 4
hypoxia
hypoventilation
hypoglycemia
delirium tremens
Emergent IC disease causes of confusion
seizure/NCSE
tbi
htn encephalopathy
Emergent systemic disease secondary effecting CNS - disease causes of confusion
sepsis
hepatic encephalopathy
uremia/renal failure
hyperthermia/hypo
endocrinopathy
nutritional deficiency
Emergent exogenous toxin causes of confusion
sedative/hallucination
etoh/toxic etoh
narcotis
antihistamine
Emergent drug w/d causes of confusion
etoh
drug of abuse
What is the aeiou mneumonic for altered mental status?
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
Key historical q/information helping with ddx confusion
new meds
infection sx
hx haed trauma
hx seizure
migraine hx
time course onset
Key PE findings to pinpoint confusion cause
Vitals
trauma
focal neuro deficit
loss attention
preservation orientation
toxidrome
Delirium vs psych vs dementia: history findings
acute onset
onset week-mo, age 12-40
onset over mo, usually >65
Delirium vs psych vs dementia: MSE
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
Delirium vs psych vs dementia: PE
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
Delirium triage screen - what is this include?
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
Brief Confusion Assessment Method: bCAM components:
- AMS or fluctuating course? –no = no delirum
if y - inattention - mo bwd dec to july –> 0-1 error = no delir
if y/ >1 error - RASS assessment –> y = no delirium
if no: - 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
The confused pt: general basic w/u
- vitals
- glucose
- DTS, bCAM
- 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
Wernicke concern - dose thiamine?
at least 100mg IV
Hypoglycemia tx
D50 amp of 5ml in 50% dextrose
or
250ml of 10% dextrose
If agitated, safe meds for pt?
haldol 1-5mg IV repeat q15 min IV or q30 min IV up tp max 10-20mg/d
Adverse effects haldol
QT prolongation
acute dystonic reaction
tardive dyskinesia
Which pt population cannot have haldol?
Parkinson’s - incr risk death
Common ways to help confusion with supportive care
1:1 sitter
quiet environment
family present if possible
avoid restraints
- 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
d
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
a
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
a
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
d
