ACUTE CONFUSIONAL STATE Flashcards
What are the causes of delirium?
P - Pain
I - Infection
N - Nutrition
C - Constipation
H - Hydration
E - Endocrine + Electrolyte
S - Stroke
M - medication and Alcohol
E - Environmental
What is the preferred test for asessing for delirium? What does it consist of?
4AT
- AMT4
- Attention
- Alertness
- Acute change?
What is the first and second line medical management of delirium?
- Haloperidol
- Lorazepam
- Both can be given PO or IM
What si the max rate of sodium replenishment in a patient with acute or chronic hyponatraemia?
In a patient with acute hyponatremia, what shoudl be the max rise i thr first hour and first 24 hours?
-
Acute
- 4-6mmol/L over 4 hours
-
Chronic
- low risk of ODS 4-8mmol/L/D
- High risk of ODS 4-6mmol/L/D
- Acute changes
- never allow sodium to rise by >5mmol in first hour
- Never allow sodium to rise by >10mmol in first 24 hours
What is the major risk associated with rapid reversal of hyponatremia?
- Pontime myelinosis
What si the most common cause of both hyponatremia in general and normovolemic hyponatremia?
- SIADH
Name a rare but important cause of hypernatremia
Diabetes insipidus
Calcium over 3 is almost always what?
Malignancy
Why is ECG important in all patients with hypercalcemia?
They may develop short QT interval
What is the management of treatment responsive hypercalcemia?
- rehydration with 6L 0.9% NaCl over 24 hours
- IV bisphosphonate
What are the two management options for patients with treatment resistant hypercalcemia?
- IM calcitonin
- PO steroids
Give two eponymous signs associated with hypocalcemia?
- Chvostek’s sign- tap facial nerve in the corner of the ear and see spasm at the side of the mouth
- Trousseau’s sign- Inflate sphygmomanometer and trigger carpopedal spasm
How do you treat acute hypocalcemia?
- Give 10ml calcium gluconate 10% solution in 100mls sodium chloride 0.9% over 10 minutes
- When sorted push on to oral calcium and vitamin D
What is the definitive cut off for treatment of hyperkalaemia?
K+ > 6.5
Name 4 cardinal signs of hyperkalaemia on ECG
- Tall tented t waves
- Widened QRS
- Flattened p waves
- prolonged PR interval
What are the stages of medical management of hyperkaemia?
- 10ml of 10% calcium gluconate over 5 minutes. Repeat every 20 minutes until ECG changes resolve
- Actrapid 10 units IV and glucose 50% 50 mL IV over 5-15 min into a large vein
- Then give glucose 5% 1 L IV in 12 hours. Monitor capillary glucose
- If glucose > 15 mmol/L, start VRII
- Administer 5-10mg of nebulised salbutamol over 30 mins
- Start Calcium Resonium 15g orally in water alongside lactulose
What can you give alongside calcium resonium to further aid removal of potassium
Lactulose
What is the treatment for mild-moderate hypokalaemia and severe hypokalaemia?
- mild-moderate- oral replacement with bananas
- severe- 20-40mmol oral KCl QDS/KCL slowly infused over IV
What is the maximum rate of KCl infusion in a non-ICU setting?
10mmol/hr
What is the CAGE questionnaire for alcohol dependence? What is considered a clinically significant score?
- Have you ever considered cutting down on alcohol?
- Does it irritate you when people suggest cutting down on alcohol?
- Do you ever feel guilty for drinking alcohol?
- Do you ever need to have a drink in the morning?
2 or more
What are the 3 pharmaceutical methods used to facilitate alcohol abstinence?
- Naltrexone- is an opioid antagonist that decreases the pleasurable activity of drinking
- Acamprosate- enhances GABA transmission, reducing cravings
- Disulfiram- inhibits ALDH which leads to a build up of acetaldehyde causing unpleasant symptoms
What are the triad of symptoms associated with delirium tremens?
- delirium-
- hallucinations
- tremor
What is the recommended pharmacotherapy in a patient beginning what is expected to be an uncomplicated detox?
- Chlordiazpoxide 20-30mg QDS gradually reducing over 5-7 days
- 100mg thiamine TDS for 4 weeks
What is the recommended pharmacotherapy in a patient beginning what is expected to be an complicated/inpatient detox?
- seizures- diazepam 10mg IV or chlordiazepoxide (100mg loading dose)
- 500mg IV pabrinex TDS should be given to prevent Wernicke-Korsakoff’s syndrome for 3 days
What is the primary deficiency cause of Wernicke-Korsaokoff’s syndrome?
What is the underlying pathophysiology of WK syndrome?
Thiamine deficiency
- In thyrotocixosis what medication is given to get initial control of symptoms?
- What medication is gicen as part of the block in block and replace therapy?
- Propranolol
- Carbimazole
What is the key investigation in suspected Addison’s disease?
In a patient with suspected Addison’s disease the definite investigation is an ACTH stimulation test (short Synacthen test). Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM.
What are the two main principles of management in an Addisonian crisis?
- Fluids and corticosteroids
- hydrocortisone 100 mg im or iv
- 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
- continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
- oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days
What is the acute management of severe acute hyponatremia?
150ml of 1.8% NaCL over 20 mins IV
What is the management of diabetes insipidus?
- Adequate fluid intake
- ADH analogue desmospressin
