Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

4Q EM Surg test 2 > Altered Mental Status > Flashcards

Altered Mental Status Flashcards

1
Q

What constitutes mental status (2)?

A
  1. Arousal-awake state, RAS & upper brainstem

2. Content: language & reasoning, communication btwn hemispheres

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Delirium may be (4)

A 
ACUTE
acute confusional state
acute cognitive impairment
acute encephalopathy
altered mental status
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Dementia types

A

CHRONIC

a. Alzheimer’s
b. AIDS related

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Delirium definition and it’s effects on 3 areas

A

TRUE MEDICAL EMERGENCY
acute onset & often fluctuation of impaired awareness, easy distraction, confusion, disturbance of perception

CONSCIOUSNESS: somnolence or agitation
COGNITION: disorientation & memory deficits
PERCEPTION: hallucinations or delusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Dementia definition & its effect on 3 areas

A

CHRONIC w/steady decline in short then long-term memory

CONSCIOUSNESS: varies
COGNITION: often subtle changes in orientation initially then progressively worsening
PERCEPTION: clear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Risk factors for delirium/dementia

A 
age>60
alcohol or drug addiction
hx of brain injury
dementia
>3 medications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Mental status

A
  • involves determining level of consciousness (U) -documented as “alert & oriented x3”
  • may be 4th area-sphere or situation (event)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What constitutes an altered mental status?

A

ANY change in either alertness or orientation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Levels of consciousness (5)

A

a point on a continuum, 5 levels:

  • alertness
  • lethargy or somnolence
  • obtunded
  • stupor or semicoma
  • coma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Alertness definition/description (4)

A
  • awake & fully aware of normal external & internal stimuli
  • can respond appropriately to any normal stimulus
  • able to interact in a meaningful way
  • altertness DOES NOT IMPLY the inherent capacity to focus attention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Lethargy or Somnolence definition/description

A

pt, not fully alert, TENDS TO DRIFT OFF TO SLEEP WHEN NOT ACTIVELY STIMULATED

  • ↓spontaneous movements & limited awareness
  • when aroused, (U) unable to pay close attention, may lose train of thought & wander from topic to topic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Obtunded: def/description

A

transitional state btwn lethargy & stupor:
difficult to arouse, when aroused they are CONFUSED
-constant stimulation required to elicit marginal cooperation from patient
-obtunded patient may be acutely confused or in a state of quiet delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Stupor or semicoma: def/description

A

used to describe patients who RESPOND TO ONLY PERSISTENT & VIGOROUS STIMULATION
-doesn’t rouse spontaneously, when aroused can only moan, mumble or move restlessly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Coma def/description

A
  • traditionally applied to patients who remain with their eyes closed & are unable to be aroused
  • does not respond to external or internal stimuli
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Orientation: in what order do you lose it (3)

A

lose orientation to TIME, then PLACE, then PERSON

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

etiologies for a change in orientation (2 broad)

A

organic vs. psychiatric

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Orientation includes which states (5)

A

confused, delusional, post-ictal, delirium, dementia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Nontraumatic etiologies of altered mental stats

A 
hypoxemia
hypo/hyperglycemia
medical conditions
OD/withdrawal
Wericke's encephalopathy
sepsis
seizure d/o
stroke
psychiatric d/o
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Traumatic etiology of altered mental status

A 
hypoxemia
acute brain injury
acute spinal cord injury
hypovolemia
psychogenic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What causes Altered Mental Status

A 
'DEMENTIA'
Drugs
Electrolytes
Metabolic
Emotional/psychiatric
Neurologic/nutritional
Trauma, tumor, temperature (syncope, seizures)
Infection, inflammation
Alcohol (use, OK, withdrawal)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the ABC (D)s

A

airway
breathing
circulation
dextrose (get finger stick blood sugar)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What do you want to pay attention to over time during the hospital stay?

A

VITAL SIGNS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What do you do when assessingrespiratory status

A

rate & effort

supplemental oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How to assess circulatory status

A

presence of pulses & quality

direct pressure over any obvious bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What must do before the rapid initial assessment?

A

make sure ABCs are good

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Rapid Initial Assesment: what is it

A

a rapid ‘visual survey’ from head to toe
initial impression of mental status
any obvious signs of airway compromise, breathing difficulty or trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Initial impression of mental status

A 
"AVPU"
Alert
Voice
Pain
Unresponsive or Unconscious if none
& pupillary response
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Coma Cocktail Contents

A

Thiamine 100mg SIVP (slow IV push)
D50 (50% glucose in water) 50 ml (25gm) over 3-4 mins
Naloxone .8-2mg IVP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

When to give the coma cocktail?

How might you determine what caused this

A

if the pt is unconscious & unresponsive w/no history
-if they wake w/in 2-3 mins, then the dx is likely either hypoglycemia or opiate OD
if not, keep looking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Laboratory workup in altered mental status

A

Blood: CMC, CMP (glucose, electrolyties, Ca/Mg, hepatic/renal fxn, thyroid panel), BAL, drug levels, blood cultures, ABG

Urine: UA, culture, UDS

Others: CSF

EKG, CXR, other x-rays as indicated, CT scan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Important components of history in altered mental status

A
  • try to determine baseline mental status
  • onset & duration of current episode
  • any specific complaints
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Physical Exam in altered mental status

A

[exam might not be done iin the (U) head-to-toe manner]
Vitals: repeat often
Skin: color, moist/dry, temp, flushing, needle tracks/sores
Neck: check for meningeal irritation, JVD
Chest: breath sounds, heart sounds, chest wall integrity
Abdomen: soft, rigid, bowel sounds, organomegaly
Neurologic: stability of pelvis, movement
Psych: agitation, tremulousness, hallucinations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

fruity breath odors a/w (3)

A

DKA, nitrites, isopropyl alcohol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

bitter almonds breath odor a/w

A

cyanide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

rotten eggs breath odor a/w

A

hydrogen sulfide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

oil or gasoline breath odor a/w

A

hydrocarbons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

odorless but fluorescent green breath a/w

A

ethylene glycol (antifreeze)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

pharmacokinetics refers to

A

body’s processing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

pharmacodynamics refers to

A

effect of drugs & their MOA

40
Q

In elderly, how often can altered mental status be attributed to medications

A

22-39%

41
Q

If someone was fumigating a ship when they exp. altered mental status, they may be intoxicated by and you would note

A

cyanide

bitter almond breath smell

42
Q

In altered mental status a/w drug intoxication, what questions should try you answer?

A

which toxin was ingested, inhaled or absorbed through the skin
how much was taken?
when was it taken?

43
Q

Causes of CHOLINERGIC poisoning (3)

A
  • organophosphates
  • nerve gas
  • mushrooms
44
Q

CHOLINERGIC POISONING treatment

A

2-PAM (pralidoxime)
or
Atropine

45
Q

Cholinergic poisoning: symptoms onset when

may lead to (4)

A

most are symptomatic within 8 hours

may lead to seizures, coma, respiratory & circulatory failure

46
Q

Cholinergic intoxication symptom mnemonics

A 
SLUDGE+Killer Bs
Salivation
Lacrimation
Urination
Defecation
GI pain
Emesis
Bradicardia, bronchorrhea, bronchospasms
-also muscle weakness
47
Q

ANTICHOLINERGIC intoxication sxs

A

hot as a hare (FEVER), blind as a bat (MYDRIASIS), dry as a bone (decreased BS, urinary retention, dry MM), red as a beet (flushing), mad as a hatter (toxic psychosis)

48
Q

Causes of anticholinergic intoxication (4)

A
  • cyclic antidepressants
  • antipsychotics
  • antihistamines
  • Jimson weed
49
Q

Anticholinergic intoxication tx

A

observation, monitoring (including temperature) & good supportive care
IE-you REALLY CAN’T REVERSE THESE

50
Q

Cardiovascular effects of TCA intoxication

A

pulmonary edema, anticholinergic effects, AV blocks (Na/K blockade), hypotension

51
Q

CNS effects of TCA intoxication

A

confusion, agitation, hallucinations, seizures or coma

52
Q

TCA intoxication tx

A

EKG monitoring, activated charcoal, Sodium Bicarbonate, benzodiazepines

53
Q

Opioid intoxication sxs& tx of intoxication

A

CNS depression, miosis, respiratory depression

-ventilation & naloxone

54
Q

Sympathomimetics (Coke & meth) intoxication sxs & tx

A

psychomotor agitation, hydriasis, diaphoresis, tachycardia, hypertension

if sever or prolonged: rhabdomyolysis, MI
tx-cooling, sedation, hydration

55
Q

Acetaminophen antidote

A

Acetylcysteine

56
Q

Anticholinergics specific antidote

A

Physostigmine

57
Q

Benzodiazepines specific antidote

A

Flumazenil

58
Q

Narcotics specific antidote

A

Naloxone

59
Q

Digoxin specific antidone

A

Digibind

60
Q

3 most common drug withdrawal types

A
  1. Delerium tremens (alcohol W/D)
  2. Sedative-hypnotic withdrawal
  3. Withdrawal seizures
61
Q

Sedative-Hypnotic withdrawal occurs when, often involves which drugs

A

occurs when pt has been taking large doses or drug over a period of 1 month or more & has abrupt discontinuation
-frequently involves barbiturates & benzodiazepines

62
Q

Clinical findings a/w sedative-hypnotic withdrawal (6)

A
  • agitation
  • tremor
  • nausea/vomiting
  • tachycardia
  • hallucinations
  • flushing

for benzos sxs may not be present for several days after d/c

63
Q

Sedative-hypnotic withdrawal tx

A

give short acting barbiturate then switch to equivalent dose of long-acting

INITIALLY give PENTOBARBITAL 300mg PO or 200mg IM q 2 hrs; repeat until patient becomes aroused

switch to PHENOBARBITAL PO then taper the dose over a max of 10 days

may need to reintroduce a benzo

64
Q

Withdrawal seizures occur with which substances & occur when

A

often earliest manifestion of abrupt decrease or abstinence from alcohol
-may be seen w/some sedative/hypnotics also

~90% of seizures occur between 6-48 hours after abstinence

65
Q

What happens if withdrawal seizures are left untreated

A

about 30% will go to develop DTs

66
Q

Withdrawal seizures: associated clinical findings

A

(U) focal seizure activity rather than tonic-clonic activity

  • pt may still be able to respond to verbal stimuli
  • rarely will lose bowel/bladder control
  • (U) NO post-ictal state
67
Q

Tx of withdrawal seizures

A

(U) self-limited & do not require anticonvulsant therapy

  • close observation for first 24 hours for reoccurrence of seizure activity
  • repetitive seizures may need single dose of Phenobarbital or Valium

…Dilantin is INEFFECTIVE

68
Q

What is the most common electrolyte abnormality

A

hyponatremia

69
Q

When do neurological sxs occur in hyponatremia?

A

when serum sodium levels fall below 120 mEq/L

70
Q

Elecrtrolyte abnormalities present with:

A

delirium, drowsiness & lethargy

-can progress to seizures & coma

71
Q

Treatment of electrolyte abnormalities?

A

aimed at underlying cause

72
Q

Common etiologies of metabolic disturbances in AMS?

A

endocrine, renal & hepatic d/os

  • can also see with thyroid storm
  • look for hx of pre-existing systemic dz
73
Q

systemic metabolic dz AMS presentation

A

market fluctuation in patient’s mental status w/intermittent periods of lucidity
& no focal abnormalities is characteristic of metabolic encephalopathy

74
Q

What should you think about first in metabolic dz a/w metabolic disturbances?

A

think endocrine first: hypo- or hyperglycemia (DM?), thyroid storm
hx (U) most helpful
physical exam rarely reveals etiology

75
Q

How to distinguish metabolic etiology vs. acute psychiatric etiology in AMS?

A

may be difficult

in acute psychiatric dz, orientation to person may be as altered as to time & place (rare in organic dz)

Psychotic pts (U) retain recent memory & are able to perform single calculations (rarely preserved in organic states)

Hallucinations
Psychosis= (U) auditory
Metabolic= (U) visual

in a large & or psych d/o there is coexisting etoh/drug use/abuse

76
Q

Acute stroke presentation

A

can vary widely

AMS, dyspasic or slurred speech, loss of movement and/or strength of one or both sides of body, asymmetrical facial features

if resolved w/in 24hrs, may be TIA

77
Q

Post-ictal states AMS

A

period after seizure when pt gradually has clearing of mental status

  • known hx of seizure d/o, witnessed seizure activity
  • may have loss of bowel/bladder control or fxn
  • should return to pre-ictal state within abt 1 hour
78
Q

Thrombotic Thrombocytopenia Purpura: description, affects who, rltd to/cause, tx

A

acute onset of fever, bleeding/rash, renal failure, neurologic changes

(U) affects women 20-40yo
-may be related to drugs, pregnancy, lupus infection

Cause: rltd to von Willebrand Factor where form small blood clots

Tx: plasma exchange & steroids

79
Q

In acute head trauma, there is a good chance of what?

A

good chance of spinal trauma so PROTECT THE SPINE

-need thorough assessment to determine if there is a spinal cord injury

80
Q

NEXUS criteria

A 
CANNOT clear C-spine if:
Intoxication
Distracting injuries
Midline posterior point tenderness
Any alteration in mental stats
Focal neurologic deficits
81
Q

Diagnostic exams/studies used in acute head trauma

A

CT (U) most helpful dx study
C-spine films

Rectal exam:
sphincter tone intact=injury is LIKELY intracranial
little or no tone=coexisting spinal cord injury

repeat neurological examinations

82
Q

Hypothermia: temp, physiological responses

A

skin temp near 91 F

peripheral vasoconstriction, shivering, altered mental status, cardiovascular changes, respiratory changes

83
Q

Moderate hypothermia

A

92-86 F

apathy, lethargy, ataxia

84
Q

Hyperthermia: types (2), temps & signs a/w each

A

Heat exhaustion: core temp may be normal 106F

signs: may be all above except CNS dysfxn

85
Q

In very young or very old ppl. with AMS, what should you think abt?

A

infection

elderly: urosepsis, pneumonia
infants: meningitis, sepsis

86
Q

How might infection/inflammatory AMS present?

A

may not be febrile
lab studies will most often reveal cause
-inflammatory cause rarely seen in ED (may be seen in lupus, giant cell arteritis, sarcoidosis)

87
Q

Acute intoxication effects/sxs

A

produces metabolic encephalopathy similar to that produced by sedative-hypnotic drugs

peripheral vasodilation, tachycardia, hypotension, hypothermia

88
Q

When does stupor occur?

A

in non-chronic alcoholics, stupor occurs when BAL reaches 250-300 mg/dL

chronic alcoholics: ALL BETS ARE OFF!!!

89
Q

Wernicke’s Encephalopathy:

what is it, what causes it, what is it characterized by, a/w, progression

A

medical emergency caused by ACUTE THIAMINE DEFICIENCY coupled with CONTINUED CARBOHYDRATE INGESTION

characterized by ophthalmoplegia, ataxia & confusion

most cases a/w alcoholism, malnutrition or both

failure to recognize & tx may result in death or permanent neurologic impairment

90
Q

More findings a/w Wernicke’s encephalopathy

A

ophthalmoplegia, ataxia & confusion

  • Nystagmus: horizontal, vertical or both
  • Sixth CN palsy
  • Truncal ataxia: wide-based, unsteady gait
  • May have extremity ataxia only, but less (C) than truncal
  • Confusion: frank delirium in 20% of cases
  • Apathy, decreased spontaneous speech
  • Tachycardia
  • Exertional dyspnea
  • Minor EKG abnormalities
  • Orthostatic hypotension
  • Peripheral neuropathy in ~80% of cases
91
Q

Sixth CN palsy: which mm. effected

A

lateral rectus
(fyi:LR6
SO4
AO3)

92
Q

Treatment of Wernicke’s encephalopathy

A

Thiamine 100mg IV immediately
continued IV infusion of 50mg per day along w/multivitamins->aka. “banana bag”
-Magnesium deficiency common, give IV replacement
-Bed rest b/c of fragile cardiovascular status

93
Q

Delirium Tremens (DTs): prevalence, when & how long does it occur

A

uncommon but life-threatening illness seen in practicing alcoholics after abstinence

(U) appears after 3-4 days of abstinence from alcohol

duration of DT is less than 24 hours in 15% and less the 3 days in 80% of cases

94
Q

clinical findings a/w delirium tremens

A
  • profoundly delirious state a/w tremulousness & agitation
  • excessive motor activity & purposeless activity such as picking at the bed sheets
  • hallucinations, typically visual
  • tachycardia, dilated pupils, fever, excessive sweating
  • no sense of situation or sphere
95
Q

Tx of delirium tremens

A

monitor for hypertension & hyperprexia

pt (U) dehydrated-needs fluid replacement therapy

Thiamine 100mg per day (IV/IM)

Multivitamin, esp. B complex & vit C

LIBRIUM (a benzo) for more tapered withdrawal & to prevent seizures

96
Q

7 most common causes of AMS

A
  1. Neurological-28% (stroke, seizure, etc)
  2. Toxicologic-21%
  3. Trauma-14%
  4. Psychiatric-14%
  5. Infectious-10%
  6. Endocrine/Metabolic-5%
  7. Pulmonary-3%
97
Q

Major Medicolegal Pitfalls

A
  • failing to exclude organic causes for mental status changes
  • vital signs are overlooked
  • beware of occult changes in mental status

4Q EM Surg test 2 (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions