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Emergency Medicine > ALOC > Flashcards

ALOC Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

DDx in these pt’s is broad

A

i. Infection
ii. Intoxicated
iii. Confused
iv. Agitated, violent
v. Neurologic
vi. Traumatic
vii. Psychiatric

altered pts are brought for Diagnosis, protection, stabilization, intervention, disposition

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2
Q

organic issue

A

= medical issue

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3
Q

functional issue

A

psychiatric

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4
Q

Disturbed level and content of consciousness

delirium or demetnia

A

Delirium

Delirium is a transient disorder characterized by impaired attention, perception, thinking, memory, and cognition.

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5
Q

Gradual onset

delirium or dementia

A

Dementia

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6
Q

Easily distracted, poor attention span

delirium or dementia

A

delirium

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7
Q

Multiple cognitive defects: memory, language, attention, orientation, visual-spatial

A

Dementia

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8
Q

visual hallucinations psych or organic?

A

a. Visual hallucinations are usually not psychiatric

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9
Q

Slower onset, acute changes, exacerbations

A

psych

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10
Q

mixed disorder

A

= Psych plus drug abuse

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11
Q

ddx to consdier with ALOC

A 
	Alcohol, withdrawal
	Epileptic Seizure
•	Post-ictal state
	Insulin (glucose)
	Opiates, other drugs	
	Uremia, liver failure
	Trauma
	Infection**
•	Especially the elderly
	Psychiatric
	Shock
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12
Q

Red Flags

A

SICK
old/young/immunocompramisEd

PE findings:
falls, trauma
rash stiff neck
focal neuro

evidence or hx of seizure

toxidrome

PMHhx

meds

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13
Q

characteristics of delirium (8)

A 
rapid onset 
disorientation 
memory loss
flucuaing ALOC
social immodesty
sxs worse a night
VISUAL HALLUCINATION
don't forget ETOH w/d
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14
Q

ALOC protocol (7)

A 
pulse ox
d stick
upreg
u tox 
ETOH level
bowel sounds 
tachy-EKG
pupils 
temperature

CAN you reverse it with NARCAN or Glucose?

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15
Q

observation and info

A 
what do you see 
hear from EMS
5150
past visits to ED 
do they have DMC?
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16
Q

history that you should get

A 
what happened?
pain?
sick?
medical problems?
fall trauma?
meds?
are you taking them?
have you used drugs or alcohol today?
ORIETNATIon ?s
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17
Q

orientation questions

A

see anything unusual?
orientation?

do you know where you are?

do you know the date?
months?
year?

who is the president?

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18
Q

traumatic ALOC hx

A 
mechanism
when? once or ore?
did you lose consciousness
what did you do after it happened?
how do you feel now?
what hurts?
HA? vomiting?
can you walk?
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19
Q

HX from family and friends

A 
onset fast or slow?
how different from normal?
happened before?
PMHx? meds ? psych hx?
recent illness or trauma?
witnessed LOC?
drus?
etoh?
delusions or paronia?
recent emotional stress?
hx of suicide attempts?
anything that could help me?
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20
Q

PE

A

vitals: EMS, triage, repeat

appearance, undress heat to toe

get permission, explain, go slow
look for toxidrome

GCS

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21
Q

GCS score

A

7-9 is significant
dead people get a 3
document

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22
Q

GCS categories and how many points are they worth

A

eye opening (4)
verbal (5)
motor (6)

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23
Q

eye opening graded on

A

spontaneous
to voice
to pain
none

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24
Q

verbal

A 
oriented 
confused
inappropriate
incomprehensible 
none
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25
Q

motor categories

A 
obeys commands
localizes
withdraws
flexes
extends to pain 
none
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26
Q

APVU

A

awake
verbal
pain
unresponsive

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27
Q

what is the ALOC (6)

A 
Vitals
d stick
pulse ox
upreg
urinte tox
etoh
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28
Q

what are you looking for in urine

A

blood
infections
ketones

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29
Q

when would you get a CK

A

– rhabdomyolysis (agitated, stimulants, down time)

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30
Q

when would you get a mag phos

A

ETOH involvement

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31
Q

consider these in a OD

A

Tylenol, ASA level

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32
Q

what RX levels should you get

A

seizure meds

digoxin

33
Q

what should you order in a new . psychosis

and why would you order them

A 
cbc 
chem
CK
mag phos 
tylenol 
ASA
med levels
HIV
TSH (myxedema) 
RPR neurosphililis
34
Q

Consider lactic acid if

A

Consider lactic acid if fever, hypotension

35
Q

why should we consider IV hydration

A

Agitated, delirium, alcohol, tox: all are not eating/caring for self

36
Q

sedation should consist of

A

IM

benzos-versed 2-5 mg

geodon 10-20mg
zyprexa-voices 5mg

visit these pts regularly!!!

37
Q

Best benzo to give

A

versed 2-4mg IV

38
Q

geodon

what is at and what is the dose

A

10-20 mg can give iM

for psych pt

39
Q

what serial exams should be done

A

monitor VS and mental status changes

recognize if getting worse or better

40
Q

other tests that should be consider

A

LP= fever and ALOC
HIV and ALOC
CA and ALOC
new delirium or new psychosis

CT- traumatic ALOC
new delirium w/o cause or any new psychosis

HIV, CA+ALOC =CT

41
Q

assume ALOC is ____ until proven otherwise

A

medical

42
Q

50% of psych pts are ___yrs of age

A

<40 yrs

43
Q

EDs responsibility with 5150

need to determine if

A

ED “medically clears” pt’s on 5150 hold

  1. ED must determine there is no medical/organic cause
  2. Psych facility is not an acute medical facility!
  3. Can be discharged home
  4. Need medical admission
  5. Need psychiatric admission
44
Q

how do you determine a medical clearance

A

dx has been established and pt is stable for transfer

pt is able to talk to a psychiatrist
sedated.intoxicated can’t be evaluate

Practitioner to practitioner transfer by phone

inform pt and family

45
Q

Ask about/uncover suicidal ideation (SI) in all psych pt’s

A
  1. Do you want to hurt yourself or anyone else?
  2. Are you feeling suicidal now?
  3. Have you thought about how you would do it?
  4. Do you have: gun, access to pills, etc…?
  5. Have you ever tried to hurt yourself before?
  6. Are you hearing voices? What are they saying?
  7. Are you seeing anything unusual?
46
Q

ABBREVIATIONS for psych episodes

A

AH = auditory hallucination

VH = visual hallucinations; SI = suicidal ideations; HI = homicidal ideations

47
Q

PE

A

i. Vitals
ii. General appearance
iii. Head to toe exam – get permission
iv. Orientation questions, Mini-Mental Status if able
v. Document if pt is unable or unwilling to cooperate with exam and why
vi. May need to examine after sedation
vii. Serial exams

48
Q

when to do a medical workup

A 
no previous psych
>40 -first psych issue 
abnormal vital signs 
impaired consciousness
recent memory loss, trauma
impaired consciousness 
focal neuro finding
49
Q

You suspect an organic, not functional etiology of this behavior change get this dx tests

A

d stick
upreg
utox

50
Q

mechanical restraints

A

Soft restraints, leathers, belts, mask

51
Q

chemical restraints

A

benzos )

antipsychotics

52
Q

benzos

A

midazolam (versed) 2-5mg IM/IV

lorazepam (ativan) 1-2mg IM/IV

53
Q

antipsychotics

A

ziprasidone (geodon) 10-20mg IM/IV 20 mg PO

Haloperidol(haldol) 2-5mg IM/IV
add congentin 1-2mg IM/IV

54
Q

rules for restraints

A
  1. Must have legitimate reason to restrain, must fill out form
  2. Restrain pt’s with other staff assisting
  3. Remove restraints with other staff present
  4. Never remove restraints from any patient you do not know
  5. Restrained pt’s must be supervised
  6. Contracts with patients - be
  7. Speak to the family about restraints
55
Q

suicide RF

A
  1. Male, white, unemployed, single
  2. Adolescents
  3. Drug and/or alcohol abuse
  4. Recent life stressor
  5. Physical/chronic illness
  6. Hx domestic violence, sexual assault/abuse
  7. Major mood disorders, 10% schizophrenic pts
  8. Lethality/Rescue ratio of plan
  9. Past attempt, family Hx of suicide
56
Q

treatment for SI

A

1.Recognition, assess risk, 5150?

  1. Suicide precautions in ED
    a. Restraints, high visibility area, “clean” area
  2. Medically clear
    a. Monitor, treat, consider overdose
    b. Repair lacerations, hydrate, etc…
  3. Psychiatric consult by phone or in person
  4. Admit to hospital or transfer to psych facility
    a. Transfers must be stable!
57
Q

d/c of SI pts

A
  1. Psychiatric/Attending MD consultation obtained
  2. Not suicidal now
  3. Risk profile low
  4. Intent, gesture for secondary gain
  5. Pt has family, friends here, now
  6. Pt has stable home environment
  7. Can f/u with psychiatrist reliably
  8. Means of lethality eliminated or regulated
58
Q

• Most common underlying cause of suicide

A

DEPRESSION

59
Q

SIGECAPS

A 
	Sadness 
	Insomnia/Hypersomnia
	Guilt
	Mood
	Energy 
	Concentration
	Appetite, activity
	Pleasure (anhedonia)
	Suicide
60
Q

types of depression

A

Organic or Functional or Situational?

– “I can’t visit my grandkids b/c my COPD has gotten really bad”-Organic

61
Q

ED role in depression

A

b. ED rarely initiates medical therapy (2 week rule – takes about 2 weeks for any antidepressant to work)

Discuss therapies – drugs help, medical model

62
Q

mania definition

A

“Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week”

63
Q

considerations in a pt with mania

A

ii. Psychiatric, medical, medications, drugs
iii. Patient a danger to themselves/others?
iv. Protect patient, protect staff

often start with benzos in these cases

64
Q

workup and tx of pt with mania

A
  1. Chemical restraint often needed – Benzo’s
    v. Good history/PE - get info
    vi. Medical work-up if new, unstable

—> ALOC Protocol, add EKG (often tachycardic), TSH, CK

need a CK and TSH because rhabdomyolisis happens when there is an inability to care for themselves and TSH for a hyperthyroid issue

65
Q

Formication

A

feel that they are infested with bugs or some sort of unusual virus; meth disease

66
Q

common dx sources of secondary anxiety

A

need to think about what is really going on with this patient

Cardiac - MI, CHF, dysrhythmias (afib)

Endocrine – thyroid, etc

Respiratory - PE (all have anxiety), asthma, COPD

Drugs-

“i’m not finding a medical problem tonight”

67
Q

rxs you want to think about in a pt with anxiety

A
  1. Sympathomimetics, caffeine, herbals, cannabis, LSD, ecstasy, benzo’s w/d!
  2. ETOH, opiate/benzo withdrawal
68
Q

vii. Anxiety Evaluation/Tx

A
  1. Patient a danger to themselves/others?
  2. Evaluate in quiet area, reassure, listen
  3. Good history, good physical
  4. ALOC Protocol
  5. EKG if tachy, chest pain; TSH
  6. Treatment-rx
69
Q

RX anxiety

A

a. Benzo’s IV, IM, PO (3-5 days MAX)
b. Psych consult, primary care referral
c. Home, family, friends
d. Benzo Rx only for 3-5 days max if discharged
i. They are in the same category as opiates

70
Q

how often do you see schizophrenia

A

 <3% population but common in ED

71
Q

story of schizophrenia in the ED

A 
   Medication non-compliance- i thought i was doing well 
	Frequent SI
	Mixed disorders, substance abuse
	Recent stressors
	Poor support/situation
	No regular psych treatment
72
Q

workup and tx od schizophrenia in the ED

A
  • May need chemical restraint, treatment
  • Benzo’s
  • Geodon, Haldol to tx sx’s - voices, agitation
  • Good history/PE - get info
  • New = medical work-up
  • Not new? What caused this change?
  • Psych consult, follow-up
73
Q

Dystonic Reaction

A
  1. Common with phenothiazines, Haldol

2. Buccolingual, oculogyric, neck

74
Q

Dystonic Reaction tx

A

Benadryl - acute IV, outpt PO

75
Q

Neuroleptic Malignant Syndrome

A

ALOC, fever, “lead pipe” rigidity, autonomic instability - rare – sick - admit

76
Q

Serotonin Syndrome

sxs

A

ALOC, fever, tremor/shakes, rigid LE’s, hyperreflexia

77
Q

GCS

A

eye opening four eyes
verbal jackson 5
motor 6 cyclin

78
Q

AEIOU

A

ALCOHOL

EPILEPTIC

INSULIN

OPIATES

UREMIA

Also trauma, infection, psychiatric, shock

79
Q

AEIOU

A

ALCOHOL

EPILEPTIC

INSULIN

OPIATES

UREMIA

Also trauma, infection, psychiatric, shock

Emergency Medicine (28 decks)

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