3- AMS & Toxicology Flashcards
Alert (level of consciousness) is defined as awake/ fully aware of surroundings, and responds appropriately to normal stimuli but does NOT imply what?
Capacity to focus attention
What level of consiousness if defined not fully alert/ drifts to sleep when not stimulated, limited awareness, and loses train of thought constantly/ consistently?
Lethargic/ somnolent
What level of consciousness is defined as difficult to arouse, and when aroused is confused, and constant stimulation is required to elicit minimal cooperation?
Obtunded
What level of consciousness is defined as not rousing spontaneously, requires persistent/ vigorous stimulation for very little response, and when aroused will moan or mumble?
Stuporous/ semicomatose
What level of consciousness is defined as “unarousable unresponsiveness”?
Coma
(severity graded by GCS 3-15)
Is decerebrate or decorticate posturing worse?
Decerebrate
What GCS score sustained for > 72 hours indicates a very poor prognosis?
≤ 8
(also intubate b/c unable to protect airway)
What is the DSM-5 criteria for major neurocognitive disorder (dimentia)? (5)
- Sig cognitive decline in ≥ one of: learning/ memory, language, exec fxn, complex attn, perceptual motor fxn, social cognition
- Impairment acquired/ sig decline from previous functioning
- Interference w/ independence
- Do not occur exclusively in context of delerium
- Not better explained by another disorder
How is delirium defined?
Disturbance of consciousness/ altered cognition that develops over a relatively short period of time, NOT characterized by focal/ lateralized neurologic findings
Delirium may require weeks or months to fully resolve. How does it affect morbidity/ mortality?
Both HIGH
Mortality x2 if medical condition + delirium
What is the greatest RF for delirium?
Underlying brain disease
(ex. dimentia, stroke, Parkinson’s)
What are the usual etiologies of AMS?
MOVE STUPID
Metabolic (hypo/ hypernatremia, hypercalcemia)
Oxygen (hypoxia)
Vascular (CVA, bleed, MI, CHF)
Endocrine (hypoglycemia, thyroid)
Seizure (postictal state)
Trauma, temperature, toxins
Uremia
Psychogenic
Infection
Drugs (intoxication/ withdrawal)
What is included in eval of AMS aside from ABC’s, pulse ox/ cardiac monitoring, and hx/ PE?
Assess vitals, mental status (GCS), pupil size, temperature
Start interventions
What labs should be ordered for a pt with AMS?
CMP, CBC, UA, pregnancy test
While trying to ID the underlying cause of AMS, what 3 meds might you consider giving to the pt? (little to no harn using even if you’re wrong)
Thiamine, dextrose, naloxone
What intervention should be reserved for tx of severe agitation or psychosis with the potential for harm to patient, providers, or family?
Low-dose haloperidol
When should benzodiazepines be avoided/ considered in the tx of AMS?
Avoided in undifferentiated AMS
Considered in withdrawl from sedative drugs/ alcohol OR anticholinergic poisoning
What drug class is not effective in preventing/ treating sxs of delirium and often create undesirable SEs?
Cholinesterase inhibitors
Physiologic excitement/ CNS stimulation will show elevations in HR, BP, RR, and temperature. What med classes have the potential to cause this?
Anticholinergics
Sympathomimetics
Central hallucinogen agents
Drug withdrawal (EtOH)
Physiologic depression/ depressed mental status will show reductions in HR, BP, RR, and temperature. What med classes have the potential to cause this?
EtOH/ methanol/ ethylene glycol
Sedative-hypnotics
Opiates
Cholinergics
Sympatholytics
Pt with polydrug OD, exposure to metablic poisons or heavy metals will display what effects?
Mixed physiologic
What procedures are used to enhance elimination of poisons?
Forced diuresis
Urine ion trapping
Hemodialysis
Exchange transfusion
What are the MOAs for antidotes?
Prevent absorption
Bind/ neutralize poisons directly
Antagonize end-organ effects
Inhibit conversion to more toxic metabolites
When might toxicity recur after giving an antidote?
Antidote eliminated more rapidly than ingested substance (ex. Naloxone)
May require repeated admin/ continuous infusion
When should you be cautious in using flumazenil for benzodiazepine reversal?
Chronic benzo use, can precipitate seizures
What is the antidote for acetaminophen?
N-acetylcysteine
What is the antidote for amitriptyline?
Sodium bicarb
What is the antidote for anticholinergics?
Physostigmine
What is the antidote for beta-blockers?
Glucagon
What is the antidote for benzodiazepines?
Flumazenil
What is the antidote for CCBs?
Calcium
What is the antidote for coumadin?
Vitamin K, FFP
What is the antidote for cyanide?
Hydroxocobalamin/ nitrates (inhaled)
What is the antidote for Digoxin?
Digoxin antibodies (Digibind)
What is the antidote for Heparin?
Protamine
What is the antidote for Hydrofluoric acid?
Calcium
What is the antidote for iron?
Desferrioxamine
What is the antidote for methanol/ ethylene glycol?
Ethanol
What is the antidote for methemoglobin?
Methyline blue
What is the antidote for opiates?
Nalaxone
What is the antidote for organophosphates/ anticholinesterases (cholinergics)?
Atropine, 2-PAM
What is the antidote for salicylates?
Urine alkalization, dialysis
What is the antidote for sulfonylureas?
Octreotide
What drugs are tested for with a urine drug screen (UDS)? (8)
Opioids, BZs, cocaine, THC, barbiturates, amphetamines, TCAs, buprenorphine
What drugs are tested for with serum screening? (8)
Acetaminophen, salicylates, carboxyHb, digoxin, Li, metals, ethylene glycol, antiepileptics
What primarily distinguishes toxidromes?
Changes in vital signs and end orgal manifestations
What labs for should be ordered for ALL poisonings, toxidromes, and patients with AMS?
Serum pregnancy test (women of childbearing age)
Fingerstick glucose
Acetaminophen/ salicylate testing (fatal co-ingestions but effective tx strategies)
What are the most common causes of a cholinergic toxidrome?
Organophosphate/ carbamate insecticides
Nerve agents (sarin)
Nicotine
What are the sxs a/w cholingergic toxidrome?
SLUDGE + the killer B’s + MIOSIS
Salivation
Lacrimation
Urination
Defecation
GI pain
Emesis
Bradycardia, bronchorrhea, bronchospasms
What is the management for a cholinergic toxidrome?
Aggressive decontamination
Atropine
2-PAM
What are the sxs a/w anticholinergic toxidrome?
Dilated pupils, agitation/ hallucinations/ delerium, flushed skin, hyperthermia, dry skin
(blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone)
Urinary retention, decreased bowel sounds, tachycardia
(the bowel and bladder lose their tone, and the heart runs alone)
*underlined = differentiation from sympathomimetic*
What are the most common causes of an anticholinergic toxidrome?
Antihistamines, plants (Jimson weed)
How is anticholinergic poisoning diagnosed?
Clinically, serum drug levels NOT helpful
What is the management for anticholinergic poisoning?
Benzos (agitation)
Activated charcoal (relatively recent, must have N AMS/ be able to protect airway)
Physostigmine
What are the most common causes of sumpathomimetic poisoning? (6)
Cocaine, amphetamines, ephedrine/ pseudoepedrine, bath salts, theophylline, caffeine
What are the sxs a/w sympathomimetic poisoning?
Diaphoresis/ moist mucus membranes, hyperactive bowel sounds, dilated pupils, seizures, hyperthermia, tachycardia/ dysrhythmia, HTN, , agitation/ hallucinations/ paranoia
Mimics “fight or flight”
Withdrawal of what appears similar to sympathomimetic poisoning?
Alcohol
What is the management for sympathomimetic poisoning?
Benzos + supportive care
Aside from opioids, what is another common cause of opioid poisoning?
Diphenoxylate
What are the sxs a/w opioid toxidrome?
Hypothermia, bradycardia, hypotension, bradypnea/ apnea, pulmonary edema, CNS depression/ coma, miosis
What is the management for opioid toxidrome?
Naloxone + supportive care
In chronic narcotic users that are breathing, how is Naloxone dosed for an opioid overdose?
Start w/ lower dose (0.4mg) to avoid precipitating withdrawal
What are the most common causes of sedative-hypnotic toxidrome? (7)
Benzos, barbiturates, GHB, carisoprodol, alcohols, zolpidem, flunitrazepam (Roofies)
What are the sxs a/w sedative-hypnotic toxidrome?
Hypothermia, vitals N, bradypnea/ apnea, CNS depression/ coma, hyporeflexia, variable pupils
What is the management for sedative-hypnotic toxidrome?
Time + supportive care
(rarely Flumazenil- can induce seizures in chronic benzo uders)
