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
