Altered Levels of Conciousness and psych Flashcards by Jason VanBrunt

What Exactly is “ALOC”?

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

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ALOC Possible causes:

Infection
Intoxicated
Confused
Agitated, violent
Neurologic
Traumatic
Psychiatric

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Why is the person acting this way?

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

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Medical vs. Psychiatric

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

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what is Delirium

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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what is Dementia

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

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what are the sx’s for Psychiatric

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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Mixed disorders

Extremely common

Psych plus drug abuse

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ALOC DDx: AEIOU TIPS

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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Red Flags in ALOC

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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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

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Biggest mistake people make

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

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Approach to the Patient

ABCDE’s first
“ALOC Protocol” on everyone

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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Reverse with Coma Cocktail (DONT)

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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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

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Traumatic ALOC questions

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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“Nuch and cranny” PE

= everything, everything.

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

Labs to Order “ALOC Protocol”

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

when to do Lumbar puncture

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

Serial Exams

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

Assume ALOC is?

medical until proven otherwise

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

so find someone who does

when to head CT?

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

IV hydration is good for who?

Agitated pt’s, delirium, alcohol, tox

What is a “5150”?

Suicidal, homicidal, gravely disabled - cannot care for self

We place pt’s on 5150 hold if necessary | We must decide if psych pt’s

Can be discharged home Need medical admission Need psychiatric admission

Psych specific questions

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?

Who gets a medical workup?

``` 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 ```

Medical Work Up? who?

Everybody - D-stick, breathalyzer, Upreg, Utox

Restraints | Chemical?

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

Restraint Rules

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

Suicide risk factors.

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

Depression Epidemiology

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

Depression mnemonic SIG-ME-CAPS

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

ED Evaluation of Depression

ED rarely initiates medical therapy (2 week rule) | Discuss therapies – drugs help, medical model

Mania def? | labs?

Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week ALOC Protocol, add EKG, TSH, CK

Anxiety - Differential Dx

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

Anxiety tx......

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

Schizophrenia tx

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

``` SE’s of Typical Antipsychotics Dystonic Reaction? Tardive Diskinesia? Orthostatic Hypotension Neuroleptic Malignant Syndrome? Serotonin Syndrome? ```

``` 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 ```