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Emergency Head and Neck > Altered Levels of Conciousness and psych > Flashcards

Altered Levels of Conciousness and psych Flashcards

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1
Q

What Exactly is “ALOC”?

A

Acute change in behavior, mentation, communication a/or level of consciousness

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2
Q

ALOC Possible causes:

A 
Infection
Intoxicated
Confused
Agitated, violent
Neurologic
Traumatic
Psychiatric
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3
Q

Why is the person acting this way?

A

New, acute process?
Acute on chronic process?
Chronic process - is patient at baseline

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4
Q

Medical vs. Psychiatric

A

Organic = medical issue(used interchangeably)
Delirium vs. Dementia
Functional = psychiatric issue

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5
Q

what is Delirium

A

Disturbed level and content of consciousness
Easily distracted, poor attention span
Disorganized thinking
Rapid onset, fluctuates throughout day
“Islands of lucidity”(ONE MINUTE OFF THE WALL then ok for a brief moment).
Psychomotor changes, hallucinations

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6
Q

what is Dementia

A

Dementia
Normal level but altered content of consciousness
Gradual onset
Multiple cognitive defects: memory, language, attention, orientation, visual-spatial

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7
Q

what are the sx’s for Psychiatric

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, judgment
Auditory hallucinations(common, but not visual hallucinations

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8
Q

Mixed disorders

A

Extremely common

Psych plus drug abuse

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9
Q

ALOC DDx: AEIOU TIPS

A 
Alcohol, withdrawl
Epileptic Seizure
Post-ictal state
Insulin (glucose)
Opiates, other drugs
Uremia, liver failure
Trauma
Infection
Especially the elderly
Psychiatric
Shock
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10
Q

Red Flags in ALOC

A 
Medical issue – sick, not just crazy
Abnormal vital signs
Fever, hypotension
Old/young/immunocomp
Findings on PE
Falls, trauma
Rash, stiff neck
Focal neuro findings
Evidence/hx of seizure(biting the tongue, peeing on yourself)
Toxidrome
PMHx
Meds: old, new, OTC, CAM
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11
Q

Delirium characteristics

A 
Rapid onset
Disorientation/short term memory loss
Fluctuating ALOC
Social immodesty
Sx’s increase at night
Visual hallucinations

Don’t forget EtOH w/d

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12
Q

Biggest mistake people make

A

put psych in the dx instead of finding the medical reason they are in the emergency dept…

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13
Q

Approach to the Patient

ABCDE’s first
“ALOC Protocol” on everyone

A 
Pulse ox, vital signs
Dextrostik (blood glucose)
Check pupils, skin
Breathilizer (EtOH)
Temperature(if you have a fever, all bets are off)
EKG if tachy or brady 
Upreg

Can we reverse this condition right now?

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14
Q

Reverse with Coma Cocktail (DONT)

A 
Dextrose - reverse hypoglycemia
Get rapid blood glucose on all ALOC pt’s
50mg of 50% dextrose (1 amp D50) IV
Oxygen
Narcan - opiate antagonist
Check pupils, consider effects, restraints
.2 - 4mg IM/IV/SL/ET  (1-2mg good start)
Thiamine - give if EtOH or unknown ALOC
Think: DON’T(coma cocktail numonic)
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15
Q

Detective work is critical

A 
Past visits to this ED
Old medical record 
Family, friends, associates
Nursing home, board and care staff
Records from other hospitals
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16
Q

Traumatic ALOC questions

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?
If you write A&O x3= you better have asked
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17
Q

“Nuch and cranny” PE

A

= everything, everything.

Document if pt is unable to, or unwilling to cooperate with exam(you may have to sedate them)

18
Q

Labs to Order “ALOC Protocol”

A 
vitals, d-stick, pulse ox, upreg, urine tox screen, EtOH (breathalyzer, blood)
Urine: blood, infection, ketones
CBC w/ diff, Chem Panel
Total CK - rhabdomyolysis
Magnesium
Tylenol, ASA level (OD’s)
Rx med levels (esp Sz meds, digoxin)
TSH, RPR in new psychosis
Consider lactic acid if fever, hypotension
19
Q

when to do Lumbar puncture

A

Fever and ALOC
HIV and ALOC
Consider in new delirium or psychosis

20
Q

Serial Exams

A

Monitor VS and mental status changes
Visit sedated patients often! Document course
Recognize if getting worse or better

21
Q

Assume ALOC is?

A

medical until proven otherwise

22
Q

To know if someone is crazy, just live with them” - you don’t

A

so find someone who does

23
Q

when to head CT?

A

Head CT
Traumatic ALOC
New delirium w/o cause or any new psychosis
HIV, CA + ALOC

24
Q

IV hydration is good for who?

A

Agitated pt’s, delirium, alcohol, tox

25
Q

What is a “5150”?

A

Suicidal, homicidal, gravely disabled - cannot care for self

26
Q

We place pt’s on 5150 hold if necessary

We must decide if psych pt’s

A

Can be discharged home
Need medical admission
Need psychiatric admission

27
Q

Psych specific questions

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?

28
Q

Who gets a medical workup?

A 
No previous psych Hx
Age >40 - first psych issue
Abnormal vital signs
Recent memory loss, trauma
Impaired consciousness
You suspect an organic, not functional etiology of this behavior change
"organic" means medical issue
29
Q

Medical Work Up? who?

A

Everybody - D-stick, breathalyzer, Upreg, Utox

30
Q

Restraints

Chemical?

A

Try talking pt down – once
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(not good for pt with seizures. it reduces the seizures threshold.
-Add Cogentin 1-2mg IM/IV, extrapyramidal effects

31
Q

Restraint Rules

A

Restrain pt’s with other staff
Remove restraints with other staff present
Never remove restraints from any patient you do not know
Restrained pt’s must be supervised

32
Q

Suicide risk factors.

A

Male, white, unemployed, single
Adolescents
Drug and/or alcohol abuse
and others.

33
Q

Depression Epidemiology

A

Most common human psychiatric disturbance – situation, illness, meds, drugs

34
Q

Depression mnemonic SIG-ME-CAPS

A 
Sadness 
Insomnia/Hypersomnia
Guilt
Mood
Energy 
Concentration
Appetite, activity
Pleasure (anhedonia)
Suicide
35
Q

ED Evaluation of Depression

A

ED rarely initiates medical therapy (2 week rule)

Discuss therapies – drugs help, medical model

36
Q

Mania def?

labs?

A

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

ALOC Protocol, add EKG, TSH, CK

37
Q

Anxiety - Differential Dx

A

Drugs
Sympathomimetics, caffeine, herbals, cannabis, LSD, ecstasy, benzo’s
ETOH, opiate/benzo withdrawal
Formication=I see bugs on my skin and wants you to help him….think (benedril) anticholinergics….mad as a hatter

38
Q

Anxiety tx……

A 
Treatment
Benzo’s IV, IM, PO
Psych consult, primary care referral
Home, family, friends
Benzo Rx only for 3-5 days max if discharged
39
Q

Schizophrenia tx

A

May need chemical restraint, treatment
Benzo’s
Geodon, Haldol to tx sx’s - voices, agitation

40
Q 
SE’s of Typical Antipsychotics
Dystonic Reaction?
Tardive Diskinesia?
Orthostatic Hypotension
Neuroleptic Malignant Syndrome?
Serotonin Syndrome?
A 
Dystonic Reaction 
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

Emergency Head and Neck (9 decks)

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