ALOC Flashcards
1
Q
what is ALOC
A
- Acute change in behavior, mentation, communication and/or level of consciousness
- AMS = altered mental status
- DDx in these pt’s is broad:
- Infection
- Intoxicated
- Confused
- Agitated, violent
- Neurologic
- Traumatic
- Psychiatric
2
Q
ED - decision
A
- Altered patients are brought to us for:
- Diagnosis, protection, stabilization, intervention, disposition
- Why is the person acting this way?
- New, acute process?
- Acute on chronic process?
- Chronic process - is patient at baseline?
- Medical vs. Psychiatric
- Organic = medical issue
- Delirium vs. Dementia
- Functional = psychiatric issue
- Organic = medical issue
3
Q
Delirium vs dementia
A
- Delirium
- Disturbed level and content of consciousness
- Easily distracted, poor attention span
- Disorganized thinking
- Rapid onset, fluctuates throughout day
- “Islands of lucidity”
- Psychomotor changes, hallucinations
- Dementia
- Normal level but altered content of consciousness
- Gradual onset
- Multiple cognitive defects: memory, language, attention, orientation, visual-spatial
4
Q
psychiatric and mixed
A
- Psychiatric
- Slower onset, acute changes, exacerbations
- VS? Otherwise - normal PE and neuro exam
- Altered content, not level, of consciousness; fantasy vs reality
- From agitated to catatonic
- Delusions: complex, paranoid, religious
- Disorganized, misplaced priorities, judgment
- Auditory hallucinations
- Mixed disorders
- Extremely common
- = Psych plus drug abuse
- Patterns overlap
- Add infection, drugs, trauma or metabolic issues to any of the above = a problem
5
Q
ALOC ddx: AEIOU tips
A
- Alcohol, withdrawal
- Epileptic Seizure
- Post-ictal state
- Insulin (glucose)
- Opiates, other drugs
- Uremia, liver failure
- Trauma
- Infection
- Especially the elderly
- Psychiatric
- Shock
6
Q
Red flags in ALOC
A
- Medical = sick, not just crazy
- Persistently abnormal VS
- Any fever, hypotension
- Old/young/immunocomp
- Findings on PE
- Falls, trauma
- Rash, stiff neck
- Focal neuro findings
- Evidence of/hx of seizure
- Toxidrome/Intoxication
- PMHx
- Meds: old, new, OTC, CAM
- Persistently abnormal VS
- Suspect delirium: characteristics
- Rapid onset
- Disorientation/short term memory loss
- Fluctuating ALOC
- Social immodesty
- Sx’s increase at night
- Visual hallucinations
- Don’t forget EtOH w/d
7
Q
approach to ALOC patient
A
- ABCDE’s first
- “ALOC Protocol” on everyone
- Vital signs, including temperature
- Undress
- Dextrostik (fingerstick glucose)
- Check pupils, skin, bowel sounds: look for toxidrome
- EKG if tachy or brady
- Alcohol level, UTox
- Upreg
- Can we reverse it? Glucose, narcan?
8
Q
observation and information - ALOC
A
- What do you hear?
- Interaction with staff, paramedics
- What do you see?
- Safety first. Are they restrained? Should they be?
- EMS information
- Details of behavior on scene
- Interventions en route
- Condition of scene
- Pill bottles, paraphernalia, disorder, chaos
- Chief complaint?
- 5150? Find & read the form
- Detective work is critical
- Past visits to this ED
- Old medical record
- Family, friends, associates
- Nursing home, board and care staff
- Records from other hospitals
- Do they appear to have DMC?
9
Q
history ALOC - simple, focused
A
- What happened today?
- Do you have pain anywhere?
- Been sick lately?
- Any medical problems?
- Any injuries - fall, trauma?
- Take medications? Are you taking them?
- Have you used drugs or alcohol today?
- Are you hearing voices?
- What are they saying?
- Seeing anything unusual?
- Orientation questions
- Know where you are?
- How did you get here?
- Do you know the date? Month? Year?
- Who’s the president?
- Make it relevant
10
Q
history ALOC - family/friends
A
- Onset fast or slow?
- How different from normal?
- When last seen normal?
- Happened before?
- PMHx, Medications? Psych Hx?
- Recently ill, trauma?
- Witnessed loss of consciousness?
- Drug and alcohol hx?
- Delusions, paranoia?
- Recent emotional stress?
- Past hx of suicide attempt?
- Anything else that might help me take care of the patient?
11
Q
Traumatic ALOC hx
A
- Mechanism
- When? Once or more?
- Did you lose consciousness?
- Before or after the injury?
- What did you do after it happened?
- How do you feel now? What hurts?
- Headache? Vomiting?
- Can you walk?
12
Q
physical exam ALOC
A
- Vitals: EMS, triage, repeat – VS are your friends
- Appearance, undress, head to toe exam
- Get permission, explain, go slow
- Look for a toxidrome
- Glascow Coma Scale – trauma
- Mini-Mental Status Exam
- If relevant and patient can cooperate
- Orientation, Registration, Naming, Reading
- Document if pt is unable to, or unwilling to cooperate with exam
- Glascow Coma Scale (3-15) (best in trauma)
- Dead people score a three; 9 or less = significant
- Eye opening (4 pts) (“four eyes”)
- Spontaneous, to voice, to pain, none (4-1)
- Verbal (5 pts) (“Jackson 5”)
- Oriented, confused, inappropriate, incomprehensible, none (5-1)
- Motor (6 pts) (“6-cylinder engine”)
- Obeys commands, localizes, withdraws, flexes, extends to pain, none (6-1)
- Eye opening (4 pts) (“four eyes”)
- APVU Scale: awake, verbal, pain, unresponsive
- Also used in trauma
13
Q
labs to consider ALOC
A
- “ALOC Protocol”: vitals, d-stick, upreg, urine tox, EtOH on all
- Urinalysis: blood, infection, ketones
- CBC w/ diff, Chem Panel
- Total CK – rhabdomyolysis (agitated, stimulants, down time)
- Magnesium, phosphorus (etoh)
- Tylenol, ASA level (OD’s)
- Rx med levels (esp Sz meds, digoxin)
- TSH, RPR, HIV in new psychosis
- Consider lactic acid if fever, hypotension
14
Q
diagnosis and treatment ALOC
A
- IV hydration is good
- Agitated, delirium, alcohol, tox: all are not eating/caring for self
- Sedation/Tx – usually IM
- Benzo’s: Versed 2-5mg IM Short acting
- Geodon10-20mg IM or Zyprexa 5mg PO for psych pt’s
- Visit sedated patients often!
- Document course
- Serial Exams
- Monitor VS and mental status changes
- Recognize if getting worse or better
- CXR and EKG
- Head CT
- Traumatic ALOC
- New delirium w/o cause or any new psychosis
- HIV, CA + ALOC
- Lumbar puncture
- Fever and ALOC
- HIV and ALOC
- Consider in new delirium or psychosis
- Charcoal? Antidote?
- Consider if OD possible
15
Q
psychiatric emergencies
A
- Up to 12% of all ED visits - difficult pt’s
- 50% <40yrs of age
- Substance abuse common co-morbidity
- Medical non-compliance
- Homelessness, unstable social situation
- Evening > Daytime
- Brought in by police, EMS vs. self present
- “5150”: Suicidal, homicidal, gravely disabled
- ED “medically clears” pt’s on 5150 hold
- ED must determine there is no medical/organic cause
- Psych facility is not an acute medical facility!
- We place pt’s on 5150 hold if appropriate, necessary. MD signs
- We must decide if psych pt’s:
- Can be discharged home
- Need medical admission
- Need psychiatric admission
- Purely psychiatric cause of ALOC is a diagnosis of exclusion
