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Gen Med: Emergency Med > Altered Mental Status > Flashcards

Altered Mental Status Flashcards

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1
Q

What should a mental status assessment determine?

A 
1. Level of consciousness
A. Drowsy
B. Stuporous
C. Comatose
2. Content of consciousness
A. Confused
B. Hallucinations
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2
Q

Define confusion

A

Lack of clarity of thinking

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3
Q

Define delirium

A

Acute confusional state

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4
Q

Define stupor

A

State in which vigorous stimuli are needed to elicit a response

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5
Q

Define coma

A
  1. Condition of unresponsiveness
  2. No eye opening, speech or spontaneous movements
  3. Motor activity is reflexive rather than purposeful
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6
Q

What 4 types of etiologies can cause confusion and delirium?

A
  1. metabolic
  2. electrolyte disturbances
  3. Endocrine disorders
  4. Neurologic
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7
Q

What are the metabolic causes of confusion and delirium?

A
  1. Hypoxia/anoxia
  2. Metabolic acidosis
  3. Infection
  4. Dehydration
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8
Q

What are the electrolyte disturbances causes of confusion and delirium?

A
  1. Hyper/hypocalcemia

2. Hyper/hyponatremia

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9
Q

What are the endocrine disorders causes of confusion and delirium?

A
  1. Hyperparathyroidism
  2. Hyper/hypothyroidism
  3. Hyper/hypoglycemia
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10
Q

What are the neurologic disorders causes of confusion and delirium?

A
  1. TIA/CVA
  2. Postictal state
  3. Post concussion
  4. Psychoses
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11
Q

What drugs have anticholinergic properties?

A
  1. Antiemetics
  2. Antihistamines
  3. Antiparkinson drugs
  4. Antipsychotics
  5. Muscle relaxants
  6. TCA’s
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12
Q

What other drugs can affect mental status?

A
  1. Alcohol
  2. Benzodiazepines
  3. Narcotics
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13
Q

What labs need to be run for a pt with confusion or delirium?

A
  1. CBC
  2. Electrolytes
  3. LFT’s
  4. BUN/Cr
  5. TSH, Free T4 if indicated
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14
Q

What further evaluation needs to be performed for a confusion delirium pt?

A 
1. Suspect infection
A. UA/ Urine C&S
B. CXR
C. Blood cultures
D. Lumbar puncture
2. Hypoxia
A. CXR
B. EKG
C. ABG
3. Suspect toxins
A. Toxicology screen
B. BAC
4. Suspect CVA or seizure
A. CT Brain
B. EEG
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15
Q

How are confused/delirious pts manged?

A
  1. Must treat underlying precipitating factor
    A. If systemic infection -> Abx
    B. If electrolyte disturbance -> correct disturbance
  2. Supportive care
    A. Frequent re-orientation by staff
    B. Preservation of sleep/wake cycles
    C. Attempt to mimic home environment as much as possible
  3. Antipsychotics at low doses only if necessary to protect pt or staff from injury
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16
Q

What are the most common causes of stupor and coma?

A
  1. Cranial trauma (TBI)
    A. Concussion
2. Brain lesions
A. Brain trauma/tumor/abscess
B. Cerebral infarct/hemorrhage
C. Epidural/subdural hematoma
D. Subarachnoid hemorrhage
E. Brain stem infarct/tumor/hemorrhage
  1. Diffuse metabolic disorders affecting cerebrum
  2. Psychiatric Disorders
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17
Q

What are the metabolic causes of stupor and coma?

A 
1. Endogenous Toxins & Deficiencies
A. Hepatic coma
B. DKA
C. Hypoglycemia/hyponatremia
D. Uremia
2. Epilepsy/Postictal State
3. Anoxia/Ischemia
A. Syncope
B. Cardiac arrhythmia
C. Pulmonary infarct/insufficiency
4. Exogenous Toxins
A. Alcohol
B. Barbiturates
C. Morphine
D. Heroin
E. Hypothermia
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18
Q

What are the psychiatric causes of stupor?

A
  1. Catatonia
    A. Disturbance of motor behavior that can have either a psychological or neurological cause
  2. Hysteria
    A. Psychoneurosis of emotional excitability & disturbances of the psychic, sensory, vasomotor, & visceral functions w/out an organic basis
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19
Q

What is the initial management plan for stuporous or comatose pts?

A
  1. Attempt to arouse patient
  2. Immediate assessment of ABC’s
  3. Postpone intubation until administration of empiric therapy consisting of “D.O.N.T.”
  4. If persistent coma after “D.O.N.T.,” definitive management of airway & breathing should be considered
  5. IV access w/ 2 large bore IV’s
  6. Aggressively manage BP
  7. Obtain Hx from friends, relatives, EMS personnel
    A. Recent head trauma, illicit drug use, PMH, medications, H/A, confusion, vomiting, others w/ similar sx’s
    B. VS, (w/temp)
    C. Focused PE to evaluate for potential precipitating factors (drug use, systemic trauma)
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20
Q

What is included in DON’t therapy?

A
  1. D: IV Dextrose
  2. O: Oxygen
  3. N: IV Naloxone (Narcan) or Flumazenil (Romazicon)
  4. T: Thiamine (Vit. B1)
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21
Q

When is the neuro assessment performed for a stuporous/comatose pt?

A

Neuro assessment ASAP after immediate threats to life addressed

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22
Q

What is included in the Neurologic assessment for a stuporous/comatose pt?

A
  1. Level of consciousness, CN & motor exam
    A. Level of consciousness -> Glasgow Coma Scale
    B. CN (pupil response) -> brainstem fxn/dysfxn
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23
Q

What are Unilateral pupil abnormalities indicative of?

A

early indicator of brainstem herniation

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24
Q

What are Symmetric reactive pupils that are unusually large or small indicative of?

A

commonly secondary to drug ingestion

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25
Q

What are large pupils indicative of?

A

hallucinogenics (LSD, marijuana), anticholinergics (antihistamines, atropine)

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26
Q

What are small pupils indicative of?

A

cocaine, opioids (heroin, hydrocodone, methadone)

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27
Q

What is included in the neuro motor exam of a stuporous/comatose pt?

A
  1. Lateralizing deficits asst with structural brain lesions
    A. May result in posturing:
    B. Decerebrate: extension of both upper & lower extremities
    C. Decorticate: flexion of upper extremities and extension of lower extremities
  2. Involuntary movements asst with metabolic cause of coma
    A. Occur in absence of cortical input
28
Q

What imaging is necessary for a comatose/stuporous pt?

A

Non-contrast CT

29
Q

What albs are necessary for a comatose/stuporous pt?

A
  1. CBC
  2. Electrolytes
  3. LFT’s
  4. BUN/Cr
  5. TFT’s
30
Q

What further evaluation is required in a stuporous or comatose pt?

A
  1. Further evaluation guided by initial evaluation
  2. Suspect infection
    A. UA/ Urine C&S
    B. CXR
    C. Blood cultures
    D. Lumbar puncture
  3. Hypoxia
    A. CXR
    B. EKG
    C. ABG
  4. Suspect toxins
    A. Toxicology screen
  5. Suspect CVA. or seizure
    A. CT Brain
    B. EEG
31
Q

How does increased intracranial pressure and herniation present?

A
  1. Manifested by Cushing’s Triad:
    A. HTN (↑ SBP ) - widening pulse pressure
    B. Bradycardia
    C. Irregular breathing (Cheyne-Stokes)
32
Q

What can cause increased intracranial pressure and herniation?

A
  1. Space occupying lesion (tumor or hematoma)
  2. Cerebral edema 2°to:
    A. Trauma
    B. Infection
    C. Severe metabolic derangements
33
Q

How is ICP treated?

A
  1. Maintain cerebral perfusion
  2. Reduce volume of cerebral edema
  3. Expand cerebral volume through surgical decompression of tumor
34
Q

How is herniation treated?

A
  1. Treatment of herniation in ED
  2. Prompt recognition
    A. Mannitol
  3. Tx hypoxia & hypotension aggressively
  4. Tx hyperglycemia & fever
  5. Elevate head @ 30 degrees
  6. Sedation, analgesia, seizure precautions
35
Q

What causes the majority of cases of intracerebral hemorrhage?

A

HTN

36
Q

What are the risk factors of ICF?

A
  1. Smoking
  2. Advanced age
  3. Anticoagulant use
37
Q

What are the sxs of intracerebral hemorhage?

A
  1. Headache, nausea, vomiting
  2. HTN
  3. Focal neurologic deficit with ↑ ICP
38
Q

What is the treatment for intracerebral hemorrhage?

A
  1. Reduce ICP
  2. Reduce BP
    A. IV Labetolol
  3. Reverse anticoagulation
    A. FFP, Vit K, protamine
  4. Prompt neurosurgery intervention
39
Q

What is the most common cause of subdural hematoma?

A

Trauma

40
Q

What are the risk factors of subdural hematoma?

A
  1. Alcoholism
    2 Seizures
  2. Coagulopathy
41
Q

What are the sxs of subdural hematoma?

A
  1. Nonspecific
  2. H/A, confusion, depressed level of consciousness
  3. May be stable or rapidly progressive
42
Q

What imaging is needed for subdural hematoma?

A
  1. Non-contrast CT Scan -> hyperdense crescent shaped extra axial collection of blood
43
Q

What is the treatment for subdural hematoma?

A
  1. Immediate hospitalization

2. Emergency neurosurgery evaluation

44
Q

What is the most common cause of epidural hematoma?

A
  1. Almost always asst w/trauma
    A. Majority in temporo-parietal region
    B. Asst w/middle meningeal art. laceration
45
Q

What are the sxs of an epidural hematoma?

A

Classic presentation of head trauma, followed by brief loss of consciousness, return to alertness, then worsening ha, vomiting, coma

46
Q

What imaging is required for an epidural hematoma?

A

Non-contrast CT -> hyperdense biconvex collection of blood that does not cross suture lines (differentiates from subdural hematoma)

47
Q

What treatment is required for epidural hematoma?

A

Stat neurosurgery consult

48
Q

When does cerebral swelling peak in a cerebral infarct?

A
  1. Hemispheric infarct -> cerebral edema (esp if infarct is large)
    A. Cerebral swelling peaks in 48-72 hrs
49
Q

What are the sxs of a cerebral infarct?

A
  1. Hemiparesis
  2. Hemisensory loss
  3. Aphasia
50
Q

What imaging is needed for a cerebral infarction?

A

Non-contrast CT

51
Q

What is the treatment for a cerebral infarct?

A
  1. Pt’s w/ massive cerebral infarction progress to coma due to ↑ ICP
  2. HTN management can ↓ ICP
    A. Goal is to reduce SBP by 15% in 1st 24 hrs if SBP > 220 mm Hg
52
Q

What causes a subarachnoid hemorhage?

A

Aneurysm accounts for 80% of cases of nontraumatic SAH

53
Q

What are the rf for subarachnoid hemorrhage?

A
  1. Smoking
  2. HTN
  3. Cocaine & alcohol use
  4. (+) FH
  5. Females
  6. African American
54
Q

What are the sxs of subarachnoid hemorrhage?

A
  1. Sudden onset of H/A
  2. N/V
  3. Photophobia
  4. ↓ Level of consciousness
  5. Markedly ↑BP
55
Q

What imaging and labs are needed for a subarachnoid hemorrhage?

A
  1. Non-contrast CT -> initial study of choice
  2. If CT (-), f/u with LP
    A. CT low sensitivity of 98-100% in first 12 hrs
    B. If CSF nl (no xanthochromia or no RBC’s), SAH is excluded
56
Q

What is the treatment for a SAH?

A
  1. ABC’s
  2. Neurosurgery for craniotomy & clipping
  3. Treat HTN aggressively
57
Q

What is a metabolic encephalopathy characterized by?

A
  1. period of progressive somnolence, intoxication, delirium or agitation initially
  2. Pt becomes stuporous & finally enters coma
  3. H/A is usually NOT a presenting sx
58
Q

How can hypoglycemia cause an encephalopathy?

A
  1. Abrupt hypoglycemia rapidly interferes w/ brain metabolism
  2. Insulin & oral hypoglycemic drug OD -> most common cause
59
Q

What are the sxs of hypoglycemic encephalopathy?

A
  1. ↑sympathetic activity (tachycardia, sweating, anxiety)
  2. May be masked by beta blockers
  3. May be absent in diabetics with autonomic neuropathy
  4. Delirium, seizures, stupor, coma
60
Q

How is hypoglycemic encephalopathy treated?

A
  1. D50 (50 ml of 50% dextrose) IV

2. Close monitoring, esp if pt is on long acting insulin or oral agent

61
Q

How can hypoxemia lead to cerebral ischemia?

A
  1. 4-6 min of asystole can lead to permanent brain damage

2. Following asystole, pupils dilate rapidly & become fixed

62
Q

How is hypoxemia induced encehpalopathy treated?

A
  1. Treat underlying cause of hypoxemia
  2. Support cardiac output
  3. Maintain pO2 above 60 mm Hg using supplemental oxygen or mechanical ventilation
63
Q

What is the most common etiology of coma in pts presenting to the ED?

A

Drug overdose

64
Q

What are hte sxs of narcotic OD?

A

Hypoventilation, pinpoint pupils

65
Q

How are drug OD pts treated?

A
  1. ABC’s
  2. Naloxone(Narcan) for suspected opioid OD
  3. Flumazenol (Romazicon) for suspected benzodiazepine OD
66
Q

What are the sxs for ethanol intixication?

A
  1. Sx’s similar to sedative-hypnotic drugs
    A. Ataxia, dysarthria, depressed sensorium
    B. Tachycardia, hypotension, hypothermia -> due to peripheral vasodilation
67
Q

How is ethanol intoxication treated?

A
  1. Supportive care

2. Thiamine & glucose

Gen Med: Emergency Med (13 decks)

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