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Emergency Med Final > ALOC & Psych > Flashcards

ALOC & Psych Flashcards

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1
Q

What is ALOC?

A

ACUTE change in behavior, mentation, communication, &/or level of consciousness

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2
Q

What is AMS?

A

altered mental status

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3
Q

What are the possible causes of ALOC/AMS

A 
infxn
intoxication
confused
agitated, violent
neurologic
traumatic
psychiatric
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4
Q

Why are altered pts brought to the ED?

A 
Dx
Protection
Stabilization
Intervention
Disposition
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5
Q

When a person is altered, we want to ask ourselves what?

A

Is it a new, acute process?
Acute on chronic?
Chronic process- is pt at baseline?

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6
Q

Medical vs. Psychiatric in ALOC/AMS

A

organic= medical issue
delirium vs. dementia
functional= psychiatric issue

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7
Q

Characteristics of delirium

A 
disturbed level AND content of consciousness
easily distracted, poor attention span
disorganized thinking
RAPID onset, fluctuates thru day
"islands of lucidity"
psychomotor changes, hallucinations
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8
Q

Characteristics of dementia

A 
normal level but altered content of consciousness
gradual onset
multiple cognitive defects:
   memory
   language
   attention
   orientation
   visual-spatial
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9
Q

Characteristics of psychiatric issues

A

slower onset, acute changes,exacerbations
normal PE, neuro exam
altered content, NOT level, of consciousness; fantasy vs reality
from agitated to catatonic
delusions: complex, paranoid, religious
disorganized, misplaced priorities, judgement
auditory hallucinations

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10
Q

Mixed d/o’s

A

extremely common

psych plus drug abuse

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11
Q

ALOC DDx: AEIOU TIPS

A 
Alcohol, withdrawl
Epileptic seizure
   post-ictal state
Insulin (glucose)
Opiates, other drugs
Uremia, liver failure
Trauma
Infxn
   esp. in elderly
Psychiatric
Shock
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12
Q

Red flags in ALOC

A 
abnormal VS
old/young/immunocompromised
PE findings: fall, trauma, rash, stiff neck, focal neuro findings
evidence/hx of seizure
toxidrome
PMH
meds: old, new, OTC, CAM
EtOH w/d
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13
Q

Red flags in ALOC- Delirium characteristics

A 
rapid onset
disorientation/ short term memory loss
fluctuating ALOC
social immodesty
sx's increase at night
visual hallucinations
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14
Q

Approach to pt

A

ABCDE’s first!

ALOC protocol on everyone

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15
Q

ALOC Protocol

A 
Pulse ox, VS
D-stick (blood glucose)
check pupils, skin
breathilizer (EtOH)
temperature
EKG if tachy or brady
UPT
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16
Q

Coma Cocktail

A

Dextrose- reverse hypoglycemia
get rapid blood glucose on all ALOC pt’s
50mg of 50% dextrose (1 amp D50) IV
O2
Narcan- opiate antagonist
check pupils, consider effects, restraints
0.2-4 mg IM/IV/SL/ET (1-2mg good start)
Thiamine- give if EtOH/ unknown ALOC
Think: DON’T

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17
Q

Hx- simple, focused

A 
What happened today?
Do you have pain anywhere?
Been sick lately?
Any medical problems?
Any injuries- fall, trauma?
Take meds? Taking now?
Used drugs/ EtOH today?
Are you hearing voices? What are they saying?
Seeing anything unusual?
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18
Q

Orientation questions

A

Know where you are?
How did you get here?
Do you know the date? Month? Year?
Who’s the president?

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19
Q

Traumatic ALOC

A 
mechanism
when? once or more?
lose consciousness?
   before or after injury?
what did you do after it happened?
how do you feel now? what hurts?
H/A? vomiting?
can you walk?
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20
Q

PE for ALOC

A

VS: EMS, triage, repeat
Appearance, undress
Head to toe exam: get permission, explain, go slow, look for toxidrome
Mini-mental status: if pt can cooperate, orientation, registration, naming, reading
document if pt is unable/unwilling to cooperate w/ exam

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21
Q

Two scales that can be used in examining ALOC pt

A

Glascow Coma Scale

APVU scale

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22
Q

Glasgow Coma Scale (3-15) best in trauma

dead people score 3; 7-9 significant

A 
Eye opening (4 pts)
  Spontaneous, voice, pain, none (4-1)
Verbal (5 pts)
   oriented, confused, inappropriate, incomprehensible, 
   none (5-1)
Motor (6 pts)
   obeys commands, localizes, withdraws, flexes, extends 
   to pain, none (6-1)
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23
Q

Glasgow Coma Scale eye opening- 4 pts

A

spontaneous 4
voice 3
pain 2
none 1

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24
Q

Glasgow coma scale verbal- 5 pts

A 
oriented   5
confused   4
inappropriate   3
incomprehensible   2
none   1
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25
Q

Glasgow coma scale motor- 6 pts

A 
obeys commands   6
localizes   5
withdraws   4
flexes   3
extends to pain   2
none   1
26
Q

AVPU Scale

A

awakes
verbal
pain
unresponsive

27
Q

Labs to order in ALOC

A 
ALOC protocol
urine: blood, infxn, ketones
CBC wi/ diff, chem pnl
total CK- rabdo
Mg2+
Tylenol, ASA level (OD's)
Rx med levels (esp Sz meds, digoxin)
TSH, RPR in new psychosis
consider lactic acid if fever, HoTN
EKG
28
Q

Head CT in ALOC pt

A

trauma
new delirium w/o cause or any new psychosis
HIV, CA + ALOC

29
Q

Lumbar puncture in ALOC pt

A

fever & ALOC
HIV & ALOC
consider in new delirium/ psychosis

30
Q

IV hydration in ALOC pt

A 
Good to do!
agitated pt's 
delirium
alcohol
tox
31
Q

Serial Exams in ALOC pt

A

monitor VS & mental status changes
visit sedated pts often! document course
recognize if getting worse/ better

32
Q

Points to remember w/ ALOC

A

can this be reversed? now?
protect the pt, staff. get ctrl
assume ALOC is medical until proven otherwise
serial VS & exams are KEY
prove to yourself the “drunk” is just drunk- beware the “frequent flyer”

33
Q

What is a 5150

A

suicidal
homicidal
gravely disabled- cannot care for self

34
Q

ED medically clears pt’s on_____________and can also place pt’s on if necessary

A

5150

35
Q

Role of ED in 5150’s

A

must r/o any medical/organic cause
psych facility is NOT an acute medical facility- we must do the medical work
purely psychiatric cause of ALOC is a dx of exclusion

36
Q

What is medical clearance?

A 
Dx established
stable, no medical issues at transfer
pt is able to talk to psychiatrist
practitioner to practitioner transfer
arrange transportation (BLS)
inform pt & family
37
Q

Approach to the psych emergency pt

A 
ABCDE's, VS, sick vs. not sick
protect pt, staff
Hx- detective work
Mental status exam/ orientation
PE
lab, diagnostics
Dx
disposition
38
Q

Hx in emergency psych pt

A 
past med hx- prior psych hx? 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?
39
Q

Psych specific hx

A

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?

40
Q

PE in psych ED pt’s

A 
VS
general appearance
head to toe exam- get permission
mini-mental status/ orientation
doc. if pt unable/unwilling to cooperate
may need to examine after sedation
serial exams
41
Q

Who gets a medical workup for psych issues?

A 
no previous psych hx
age>40- 1st psych issue
abnormal VS
recent memory loss, trauma
impaired consciousness
-u suspect an organic, not functional etiology of this behavior change
42
Q

Medical workup for psych problems

A 
ALL- D-stick, breathalyzer, UPT, Utox
Specific:
CBC, Chem pnl, UA
Rx drug levels, Tylenol, ASA
TSH, RPR, B12
EKG, CXR
consider CK-esp. w/ stimulants
consider lactate- fever, infxn
consider head CT, lumbar puncture
43
Q

Mechanical restraints

A

soft restraints
leathers
belts
mask

44
Q

Chemical restraints

A 
Benzos
   Midazolam (Versed) 2-5 mg IM/IV
   Lorazepam (Ativan) 1-2 mg IM/IV
Antipsychotics
   Ziprasidone (Geodon) 10-20 mg IM, 20 mg PO
   Haloperidol (Haldol) 2-5 mg IM/IV
      add Cogentin 1-2 mg IM/IV, EPS
45
Q

Restraint rules

A 
restrain pt w/ other staff
remove restraints w/ other staff present
Never remove restraints from any pt you do not know
restrained pt's must be supervised
contract with pts- beware
46
Q

Suicide Risk Factors

A 
male, white, unemployed, single
adolescents
drug &/or alcohol abuse
recent life stressor
physical/chronic illness
hx of domestic violence, sexual assault/abuse
major mood d/o's, 10% schizophrenic pts
lethality/ rescue ratio of plan
past attempt, family hx of suicide
47
Q

Tx of suicidal pts

A 
recognition, assess risk, 5150?
suicide precautions in ED
   restraints, high visibility area, "clean" area
medically clear
   monitor, tx, consider OD
   repair lacerations, etc
psych consult
admit/transfer to psych facility
 transfers must be stable
48
Q

Discharging suicidal pts

A 
psychiatric consultation obtained
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 w/ psychiatrist reliably
means of lethality eliminated/ regulated
49
Q

Epidemiology of depression

A 
MC human psychiatric disturbance- situation, illness, meds, drugs
MC underlying cause of suicide
most costly to society
genetic disposition
modern complications
   media, world events
   immigrant displacement
50
Q

Depression mnemonic

SIG-ME-CAPS

A 
Sadness
Insomnia/Hypersomnia
Guilt
Mood
Energy
Concentration
Appetite, activity
Pleasure (anhedonia)
Suicide
51
Q

ED eval of depression

A

pt a danger to self? others? need a 5150?
organic vs. functional vs situational?
diagnostics
ALOC protocol, add TSH
disposition based on severity
suicide risk, ability to care for self, support
ED rarely initiates medical therapy (2 wk rule)
Discuss therapies- drugs help, medical model

52
Q

DSM definition of mania

A

distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week
psychiatric, medical, meds, drugs

53
Q

Evaluating & treating mania

A 
pt a danger to self? others?
protect pt, protect staff
   chemical restraint often needed-Benzo's
good hx/ PE- get info
medical workup if new, unstable
ALOC protocol, add EKG, TSH, CK
psychiatric consult, 5150?
54
Q

Anxiety DDx

A

really common; fear of illness
cardiac- MI, CHF, dysrhythmias
endocrine- thyroid
respiratory- PE, asthma, COPD

55
Q

Drugs that may cause anxiety

A 
sympathomimetics
caffeine
herbals
cannabis
LSD
ecstasy
benzo's
56
Q

Some psychiatric causes of anxiety

A

mania
depression
schizophrenia

57
Q

Anxiety eval & tx

A 
pt a danger to self? others?
evaluate in quiet area, reassure, listen
good hx, good PE
ALOC protocol
EKG if tachy, CP; TSH
Tx:
   Benzo's IV/IM/PO
   Psych consult, primary care referral
   Home, family, friends
   Benzo Rx only for 3-5 days max if d/c
58
Q

Schizophrenia general

A

s, substance abuse
recent stressors
poor social support/situation
no regular psych tx

59
Q

Evaluation of schizophrenia

A 
danger to self? others? 5150?
protect the pt, staff
may need chemical restraint, tx
   benzo's
   geodon, haldol to tx sx's- voices, agitation
good hx/ PE- get info
new= medical work-up
not new? what caused this change?
psych consult, follow-up
60
Q

Side Effects of typical antipsychotics

A 
Dystonic rxn
   Buccolingual, oculogyric, neck
   Benadryl- acute IV, outpt PO
Tardive Diskinesia
   involuntary: lips, face, extemities
Orthostatic HoTN
Neuroleptic Malignant Syndrome
Serotonin syndrome
61
Q

Neuroleptic Malignant Syndrome

A 
ALOC
fever
"lead pipe" rigidity
autonomic instability
rare-sick-admit
62
Q

Serotonin Syndrome

A 
ALOC
fever
tremor/shakes
rigid LE's
hyperreflexia

Emergency Med Final (9 decks)

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