ALOC

Question 1

what is ALOC

Answer 1

• 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

Question 2

ED - decision

Answer 2

• 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

Question 3

Delirium vs dementia

Answer 3

• 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

Question 4

psychiatric and mixed

Answer 4

• 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

Question 5

ALOC ddx: AEIOU tips

Answer 5

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

Question 6

Red flags in ALOC

Answer 6

• 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
• 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

Question 7

approach to ALOC patient

Answer 7

• 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?

Question 8

observation and information - ALOC

Answer 8

• 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?

Question 9

history ALOC - simple, focused

Answer 9

• 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

Question 10

history ALOC - family/friends

Answer 10

• 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?

Question 11

Traumatic ALOC hx

Answer 11

• 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?

Question 12

physical exam ALOC

Answer 12

• 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)
• APVU Scale: awake, verbal, pain, unresponsive
  
  • Also used in trauma

Question 13

labs to consider ALOC

Answer 13

• “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

Question 14

diagnosis and treatment ALOC

Answer 14

• 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

Question 15

psychiatric emergencies

Answer 15

• 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

Question 16

what is “medical clearance”

Answer 16

• Diagnosis established
• Stable: no medical issues at transfer
  
  • Work up, injuries addressed, vitals normal
• Pt is able to talk to psychiatrist
  
  • Sedated/intoxicated pt’s can’t be evaluated
• Practitioner to practitioner transfer by phone – be ready
• Arrange transportation (BLS)
• Inform patient and family

Question 17

approach to the patient

Answer 17

• ABCDE’s, Vitals, ALOC Protocol, Sick or not Sick?
• Protect the patient, protect the staff
• History - detective work
• Mental Status exam/Orientation
• Physical Exam
• Lab, diagnostics
• Diagnosis
• Disposition

Question 18

history of psych emergency

Answer 18

• Calm, non-judgemental, professional
• What happened? Why are you here?
• How did you get here?
• Can’t get coherent Hx?
  
  • 5150 form
  • Paramedic run sheet
  • Hospital records
  • Family, friends, caretakers, witnesses
• Past Medical Hx: Prior psych history? Any med problems?
• Meds - big clue - are you taking them? OTC, CAM
• Habits - anything today?
• ROS – focus on the biggies
• Social Hx
  
  • Life stressors, events, living situation
  • Has anyone hurt you lately?
  • Is there anyone I should call?

Question 19

History for SI

Answer 19

• Ask about/uncover suicidal ideation (SI) in all psych pt’s
  
  • Do you want to hurt yourself or anyone else?
  • Are you feeling suicidal now?
  • Have you thought about how you would do it?
  • Do you have: gun, access to pills, etc…?
  • Have you ever tried to hurt yourself before?
  • Are you hearing voices? What are they saying?
  • Are you seeing anything unusual?
  • Screening at triage is a Joint Commission imperative
    
    • Desire to be dead or not wake up…SI without plan….SI with plan, preparation, attempt…in the past month

Question 20

physical exam for SI

Answer 20

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

Question 21

medical workup

Answer 21

• Who gets a medical workup?
  
  • No previous psych Hx
  • Age >40 - first psych issue
  • Abnormal vital signs
  • Recent memory loss, trauma
  • Impaired consciousness
  • Focal neurologic finding
• You suspect an organic, not functional etiology of this behavior change
• Everybody - D-stick, Upreg, Utox
• Specific patients consider:
  
  • CBC, Chem panel, UA, serum etoh
  • Rx drug levels, Tylenol, ASA
  • TSH, RPR
  • EKG, CXR
  • Consider creatinine kinase – especially w/ stimulants – high CK = rhabdomyolysis
  • Consider lactic acid if fever, hypotension, infection
  • Consider head CT, lumbar puncture if new, different, fever

Question 22

violent patients

Answer 22

• Predictable and unpredictable
• Listen: the obvious and your gut
• Inappropriate patients should be treated with great care, apprehension
• Assessment from safe distance
  
  • Know your space
  • Exam with another person at bedside or within view

Question 23

restraints

Answer 23

• Protect the patient, protect the staff
• Try talking pt down – once
• Decide, inform, then act as one
• Mechanical
  
  • Soft restraints, leathers, belts, mask
• Chemical
  
  • Benzodiazepines
    
    • Midazolam (Versed) 2-5mg IM/IV*
    • Lorazepam (Ativan) 1-2mg IM/IV
  • Antipsychotics
    
    • Ziprasidone (Geodon) 10-20mg IM, 20mg PO
    • Haloperidol (Haldol) 2-5mg IM/IV
      
      • Add Cogentin 1-2mg IM/IV, extrapyramidal effects
• Restraint rules
  
  • Must have legitimate reason to restrain, must fill out form
  • Restrain pt’s with other staff assisting
  • Remove restraints with other staff present
  • Never remove restraints from any patient you do not know
  • Restrained pt’s must be supervised
  • Contracts with patients - beware!
  • Speak to the family about restraints

Question 24

suicide

Answer 24

• Risk factors
  
  • Male, white, unemployed, single
  • Adolescents
  • Drug and/or alcohol abuse
  • Recent life stressor
  • Physical/chronic illness
  • Hx domestic violence, sexual assault/abuse
  • Major mood disorders, 10% schizophrenic pts
  • Lethality/Rescue ratio of plan
  • Past attempt, family Hx of suicide

Question 25

treatment of suicidal pts

Answer 25

• Recognition, assess risk, 5150?
• Suicide precautions in ED
  
  • Restraints, high visibility area, “clean” area
• Medically clear
  
  • Monitor, treat, consider overdose
  • Repair lacerations, hydrate, etc…
• Psychiatric consult by phone or in person
• Admit to hospital or transfer to psych facility
  
  • Transfers must be stable!

Question 26

discharging suicidal pts

Answer 26

• Psychiatric/Attending MD consultation obtained, agree
• Not suicidal now
• Risk profile low
• Intent, gesture for secondary gain
• Pt has family, friends here, now
• Pt has stable home environment
• Can f/u with psychiatrist reliably
• Means of lethality eliminated or regulated

Question 27

depression

Answer 27

• Epidemiology
  
  • Most common psych disturbance – situation, illness, meds, drugs
  • Most common underlying cause of suicide
  • Most costly to society
  • Genetic disposition
  • Modern complications
    
    • Media, world events
    • Immigrant displacement
• SIG-ME-CAPS
  
  • Sadness
  • Insomnia/Hypersomnia
  • Guilt
  • Mood
  • Energy
  • Concentration
  • Appetite, activity
  • Pleasure (anhedonia)
  • Suicide

Question 28

ED evaluation of depression

Answer 28

• Patient a danger to themselves or others? Need a 5150?
• Organic or Functional or Situational?
• Diagnostics
  
  • ALOC Protocol, add TSH
• Disposition based on severity
  
  • Suicide risk, ability to care for self, support
  • ED rarely initiates medical therapy (2 week rule)
  • Discuss therapies – drugs help, medical model

Question 29

mania eval/treatment

Answer 29

• “Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week”
• Psychiatric, medical, medications, drugs
• Patient a danger to themselves/others?
• Protect patient, protect staff
  
  • Chemical restraint often needed – Benzo’s
• Good history/PE - get info
• Medical work-up if new, unstable
• ALOC Protocol, add EKG, TSH, CK
• Psychiatric consult, 5150?

Question 30

anxiety - differential dx

Answer 30

• Really common; huge DDx
• Cardiac - MI, CHF, dysrhythmias
• Endocrine – thyroid, etc
• Respiratory - PE, asthma, COPD
• Drugs
  
  • Sympathomimetics, caffeine, herbals, cannabis, LSD, ecstasy, benzo’s
  • ETOH, opiate/benzo withdrawal
  • Formication
• Psychiatric
  
  • Mania, depression, schizophrenia

Question 31

anxiety eval/tx

Answer 31

• Patient a danger to themselves/others?
• Evaluate in quiet area, listen, reassure
• Good history, good physical
• ALOC Protocol
• EKG if tachy, chest pain; TSH
• Treatment
  
  • Benzo’s IV, IM, PO
  • Primary care referral, psych if danger to self
  • Referrals for counseling, groups, etc
  • Benzo Rx only for 3-5 days max if discharged

Question 32

schizophrenia

Answer 32

• <3% population but common in ED
• Medication non-compliance
• Frequent SI
• Mixed disorders, substance abuse
• Recent stressors
• Poor support/situation
• No regular psych treatment
• Danger to themselves/others? 5150?
• Protect the patient, staff
• May need chemical restraint, treatment
  
  • Benzo’s
  • Geodon, Haldol, Zyprexa 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

Question 33

SE’s of typical antipsychotics

Answer 33

• Dystonic Reaction à
  
  • Buccolingual, oculogyric, neck
  • Benadryl - acute IV, outpt PO
• Tardive Diskinesia
  
  • Involuntary: lips, face, extrem
• Orthostatic Hypotension
• Neuroleptic Malignant Syndrome
  
  • ALOC, fever, “lead pipe” rigidity, autonomic instability - rare – sick - admit
• Serotonin Syndrome
  
  • ALOC, fever, tremor/shakes, rigid LE’s, hyperreflexia