Altered Mental Status Flashcards
Altered Mental Status:
A
- Alcohol: methanol, ethylene glycol, isopropyl, EtOH (AKA, Wernicke’s, DTs) Ammonia: liver failure, Reye’s Arterial Gas Embolism,
acidosis
Altered Mental Status:
E
Encephalopathy: HTN, hepatic
Electrolyte: K, Na, Ca, Mg
Endocrine: Thyroid, Adrenal
Exposure: Hyper / hypothermia
Altered Mental Status:
I
Insulin: Hypoglycemia, DKA, Hyperosmolar non-ketotic state
Altered Mental Status:
O
Oxygen: MI, PE, CVA, COPD, hypoxia, O2 toxicity, hypercarbia
Altered Mental Status:
U
Uremia: ARF, CRF
Altered Mental Status:
T
- Trauma: epidural, subdural, SAH, DAI, concussion, NAT
Toxins: CO, CN, organophosphates, sympathomimetics, opiates, THC, NMS, benzos, ecstasy, GHB, LSD, PCP, serotonin syndrome,
Tumor
Thiamine deficiency
Thyroid (storm or myxedema)
Altered Mental Status:
I
Infection: meningitis, encephalitis, sepsis, UTI, CJD, endocarditis, toxoplasmosis, crypto, TB
Altered Mental Status:
P
Psych: Delirium, dementia, psychosis, Paraldehyde, Porphyria
Altered Mental Status:
S
Seizure, Syncope, Shock (many kinds)
Altered Mental Status:
ASAP:
ABCs, IV, O2, monitor/EKG, accu✓, VS w rectal temp, C-collar if ?, RSI/ETT, full primary survey.
If accu✓ < 80… give 1 amp D50 IV
If malnourished… Thiamine 100mg IV
If drugs… Narcan 0.4-2mg IV/IM
If ↓BP… IV fluid bolus x 2
Altered Mental Status:
If meningitis…
dexamethasone (10mg IV)
ceftriaxone 2 mg
+/- vancomycin 1 g
ampicillin (listeria)
acyclovir (10 mg/kg)
Altered Mental Status:
If meningitis..Neonates
- GBS, listeria, gram neg bacilli
– ampicillin 50 mg/kg
+ cefotaxime 50 mg/kg or gentamicin 2.5 mg/kg
Altered Mental Status:
If meningitis…Infants
- GBS, listeria, H flu, S. pneumo, N. men- Cefotaxime 50mg/kg or ceftriaxone 100 mg/kg +vancomycin and ampicillin for
resistance
Altered Mental Status:
If meningitis…3mo-18 yrs
- H flu, s. Pneumonia, N men- Ceftriaxone (max 2 g) + vancomycin 15-20 mg/kg for resistance
Altered Mental Status:
If meningitis…18-50
- s. Pneumonia, n.men- Ceftriaxone (max 2 g) + vancomycin 15-20 mg/kg for resistance
Altered Mental Status:
If meningitis…>50, immunosuppressed, alcoholic
S. Pneumonia, n. Men, listeria, aerobic gram neg- Ceftriaxone 2 g, ampicillin 2 g, +
vancomycin for resistance
Altered Mental Status:
If myxedema coma…hypothyroid state signs and symptoms
Decrease T4 and T3- stressor ignites- hypothermia, hypotension, bradycardia, hypoxia,
non-pitting edema- low voltage, diffuse T wave inversions- hyponatremia, increased CPK and LDH, hypocalcemia (if s/p thyroidectomylong
QT), elevated WBC, elevated TSH
Altered Mental Status:
If myxedema coma…hypothyroid treatment
Supportive (IVF, glucose, antibiotics if infection), treat hyponatremia, hydrocortisone 100 mg q8, Thyroxine 400-500 mcg
Altered Mental Status:
Thyroid storm presentation
Hyperthyroidism plus stressful event- fever, AMS, tachycardia, widened pulse pressure, diaphoresis, goiter,
exophthalmos, a fib, CHF- TSH decreased, elevated free T4
Altered Mental Status:
Thyroid storm treatment
Propranolol- decrease stim of adrenergic receptors, blocks peripheral conversion of T4→ T3- 1 mg q 10-15min
methimazole (PTU in pregnancy)- block synthesis of new thyroid hormone (PTU blocks conversion)
PTU- 600-1000 mg → 100-300 mg q4-6 hrs
Methimazole- 90-120 mg
Steroids- prevent adrenal hyperfunction, decrease conversions
Hydrocortisone 100 mg q8 or Dexamethasone 2 mg q 6h
Iodide- inhibits release of hormone- give 1 hour after antithyroid medications
Altered Mental Status:
Hx:
Pt, family bystanders, EMS, medical records, meds, SAMPLE hx
Altered Mental Status:
Exam:
Review VS, reassess life threats, evidence of trauma or toxidromes, GCS, pupils/papilledema
Altered Mental Status:
Labs:
VBG w co-ox, CBC, BMP, LFT, lipase, coags, EtOH, NH3, lactate, TSH, T&C/S, ASA, APAP, drug levels, UA, hCG, UDS. CSF: cell counts, GS/Cx, prot/gluc, HSV PCR, crypto antigen
Altered Mental Status:
Rads:
CXR, FAST, CT head non-con (before LP!)
Altered Mental Status:
Tx:
Supportive, guided by clinical picture
