Altered Mental Status - Exam 3 Flashcards
Define AMS
a change in the clinical state of emotional and intellectual functioning of an individual
______ behavior deemed unusual for the individual or deviates from societal norms. How would someone describe them?
confusion
often uncooperative or combative
_____ an acute change in attention and mental functioning
delirium
_____ a slow onset of cognitive dysfunction that is chronic in nature
dementia
** _______ The patient’s eyes open, looks at you and when spoken to in a normal tone of voice and responds fully and appropriately to stimuli.
alertness
**______ The patient appears drowsy but opens eyes when spoken to in a loud voice and looks at you, response to questions, and then falls asleep.
lethargy
**______ The patient opens the eyes when tactile stimulus is applied and looks at you but responds slowly and is somewhat confused
obtundation
**______ The patient arouses only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases
stupor
**_____ The patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli
coma
If patient awake, alert without neuro deficit, perform ____ to differentiate confusion and delirium from a psychiatric disorders
mini mental status exam
How many liters can you give of oxygen in a normal NC?
1-4 LPM NC
liters per minute
How many liters per minutes can you give in a high flow NC?
up to 10 liters per minute
How many liters per minute can you give in a simple mask? non-rebreather?
6-10 LPM simple mask
10-15 LPM non-rebreather
What are the steps for initial evaluation in a pt with AMS?
take vitals: including O2 and POC glucose
Assess for shock: s/s of hypoperfusion
if hypoxic -> ABG
obtain 2 large bore IV catheters
obtain hx once the pt is stable: “What is the pt’s last known normal?”
What 3 treatments are fairly safe to administer without a diagnosis in patients with abnormal LOC?
dextrose
thiamine (B1) -> any s/s of malnutrition, should be thinking of thiamine deficiency
nalaxone
What is one super important questions to know when working a pt up for AMS?
when the last known normal was!!
What is considered abrupt, rapid vs gradual with regards to onset of symptoms?
abrupt: seconds to minutes
rapid: worse over days
gradual: days to weeks
What are some ddx that would present with abrupt timing?
ischemia, subarachnoid hemorrhage, seizure
seconds to minutes
What are some ddx that would present with rapid timing?
delirium
rapid: worse over days
What are some ddx that would present with a gradual timing?
space occupying lesion, dementia, psychiatric disorders
days to weeks
What are some ddx that would present with a fluctuating timing?
seizures, subdural hematoma, metabolic disorders, delirium
What is in the ddx if the pt reports history of similar symptoms of AMS?
seizures, TIA’s, delirium
What is Wernicke’s encephalopathy? What is the presentation?
thiamine B1 deficiency due to chronic alcohol use/chronic malnutrition
confusion
eye muscle weakness
ataxia
What are things you want to assess during your PE of a pt with AMS?
Assess alertness/orientation: ask A&O x3
Fundoscopic exam
Neurologic assessment: see next card
GCS
What are the components of the neurologic assessment in an unconscious pt?
https://docs.google.com/presentation/d/1icC-bUOBXcV9Ny5Rrk5S7GGy-1A34EdYWoVF1Kcs1Kk/edit#slide=id.g27ce96e0db_0_259
do it!!!
Draw the glascow coma scale
What does the six-item screener assess for? When it is used?
3 item memory recall
year, month, day of week
assess for confusion in adults
What does attention span help you differentiate? What are the 3 components?
differentiates between confused states and mental illness
digit span, serial 7s, spell backwards
If your pt is awake, alert and has normal vitals and the mental status exam reveals disorientation and memory problems, what does it indicate?
indicate medical or neurologic illness
If your pt is awake, alert and has normal vitals and the mental status exam reveals disorders of thought content/attention, what does it indicate?
psych causes of AMS: psych illness
If concerned for DKA should order _______. What value is it testing?
Serum β-hydroxybutyrate (serum ketones)
Ammonia
What is the lab test for carbon monoxide poisoning?
Carboxyhemoglobin
What is the lab test for alcohol?
Blood alcohol concentration (BAC)
interchangable with EtOH level
same test depending on the facility
**When should you order a head CT in AMS? What type?
if focal neurologic signs, papilledema or fever
**head CT w/o contrast
**What are the indications for a LP? **What are the relative CIs?
**CNS infection, SAH not seen on CT
**relative CI: cerebral edema and increased ICP
**What are the recommendations with regards to a CT scan BEFORE LP?
Immunocompromised state
History of CNS disease : mass lesion, stroke, or focal infection
New onset seizure (within one week of presentation)
Papilledema
Abnormal level of consciousness
Focal neurologic deficit
What level is a spinal tap performed? Watch the video (it is a learning objective)
A spinal tap, or lumbar puncture, is typically performed in the lower back, between the L3-L4 or L4-L5 interspace to access the subarachnoid space and collect cerebrospinal fluid (CSF)
https://www.youtube.com/watch?v=O_RjwNMZws8
______ an acute alteration in level of consciousness with change in cognition or perceptual disturbance
delirium
What are the 4 key features of delirium?
Disturbance in attention (ability to direct, focus, sustain or shift attn) and awareness (orientation) that develops over HOURS-DAYS
Fluctuation in symptoms over a 24 hour period
Disturbance in cognition: memory, orientation, language, perception, visuospatial
Sleep-wake cycles disrupted
______ a slow decline in cognition involving one or more cognitive domains. What does it commonly affect?
dementia
learning and memory, language, executive function, complex attention, perceptual-motor, social cognition
What are the pharm options that help to tx acute delirium? What is the dosing for elderly pts?
haloperidol (Haldol) 5-10 mg PO or IM
lorazepam (Ativan) 0.5 - 2 mg PO, IM, IV
start with lower doses for elderly pts
**What are the 2 SEs that need to be monitored for when using haloperidol? Can give _____ to help
Monitor frequently for extrapyramidal symptom and QT prolongation
can give Benadryl to help with extrapyramidial symptoms
What SE do you need to monitor for when using lorazepam?
Monitor for respiratory depression
In both delirium and dementia, can use ______ to control psychosis, agitation or severely disruptive or dangerous behaviors. What is the disposition for both?
antipsychotic
delirium: Admit patient unless cause is identified, treatment initiated, and improvement seen in ED
dementia: Admit unless patient has long-standing stable symptoms, consistent caregivers and reliable follow up for outpatient evaluation
After administration of narcan, what should you do next? Can this pt sign out AMA?
the patient should be observed for 1-1.5 hours prior to discharge
YES!!! but the pt needs to be competent
What is considered hypoglycemia is children? _____ have transient hypoglycemia for the first week of life
Diagnosis with glucose of < 45-50 mg/dL but needs to be consistently below that level!!!
Neonates
What is the tx for hypoglycemia in a neonates?
initial dose of 5 mL/kg of 10% dextrose
Maintenance: 6-8 mg/kg/minute of 10% dextrose (D10W)
neonates is LESS than 28 days old
What is the tx for hypoglycemia in infants and older children?
initial dose of 1-2 mL/kg of 25% dextrose
6-8 mg/kg/minute of 10% dextrose (D10W)
What routes does dextrose come in? What should you do next if that if not an option?
IV, IO, enteral (PO or NG tube)
Glucagon 0.5 mg (<25 kg) or 1 mg (>25 kg) IM, if unable to get IV, IO or NG
What is the disposition for a kiddo with hypoglycemia?
Admit all children requiring ED resuscitation
What is the tx for hypoglycemia in adults?
via IV
In hypoglycemia in adults, add on ______ if hypoglycemia is refractory and related to sulfonylurea use. Why does it work?
octreotide
prevents the release of insulin from the pancreas
What is the tx for hypoglycemia in pts with a insulin pump?
resuscitate with dextrose
DO NOT remove the pump
consult endocrinology to lower pump basal rate
What is the disposition criteria for a pt with hypoglycemia?
admit: patients who have hypoglycemia related to long acting agents need admitted for serial glucose monitoring
if discharging the pt -> educate to continue carbohydrate intake and monitor glucose
What are considered long acting agents in hypoglycemia?
sulfonylureas
long-acting insulins
meglitinides
Sulfonylureas - glipizide, glyburide, glimepiride
Meglitinides: Prandin (repaglinide) and Starlix (nateglinide)
What type of DM is DKA common in? **What are the 6 “I’s” of DKA?
type I
infection
infarction
insult (to the body)
infant (pregnancy)
indiscretion (lack of care)
insulin (absence)
basically sums up all the potential causes of DKA
What are the 5 main actions of insulin?
What is the pathophys behind DKA?
aka it has a huge snowball effect of too much glucose in the blood
aka kidneys try to compensate and pee out the glucose
What will a pt in DKA present like? Which two are the first ones occur?
hyperglycemia: polydipsia** first
polyuria: resulting in the osmotic diuresis and electrolyte imbalance ** first
s/s of volume depletion: dry mucosal membranes, poor skin turgor, orthostatis, hypotension, shock, decreased GFR, altered LOC
acidosis: tachypnea, Kussmaul respirations, fruity breath, abdominal pain, N/V
What labs should you order in DKA?
POC gluocse
CBC: looking for signs on infection
CMP
Phosphate
Magnesium
ABG/VBG
UA
Serum ketones
EKG: MI and signs of increased K
**What are the lab diagnostic criteria for DKA?
What is the difference between ABG/VBG?
can order just a VBG if all you need to pH
hypoxic patients needs ABG
If UA is positive for ketones, what should you do next?
order serum ketones for confirmation
What does CO2 in a CMP reflect?
bicarb level
What are the risk factors for pts who are in DKA but have a glucose of less than 250?
What are the 5 goals of DKA management? What is the disposition?
- volume repletion
- reverse insulin insufficiency
- correct electrolyte and acid/base imbalance
-identify and tx precipitating causes
-avoid complications
ALL DKA pts get admitted!!
What is step 1 expanded for DKA?
fluids within the first hour!!
aka fluid replacement, then check Na and adjust accordingly
What is the expanded step 2 in tx of DKA?
correct K deficits
What should you do in DKA if the K is above 5.2?
start insulin
What should you do in DKA if the K is between 3.3-5.2?
Add 20-30 mEq of K+ to each liter of NS and start insulin
What should you do in DKA if the K is less than 3.3?
Hold insulin, administer K+ until K+ is > 3.3
recheck K every 2 hours until K is above 3.3
What is expanded step 3 in DKA tx? **What are the 2 dosing options?
Initiate regular insulin as soon as safely possible (based upon K+)
**2 dosing options (one is not better than the other)
0.1 U/kg bolus, then 0.1 U/kg/hr
0.14 U/kg/hr without a bolus
What is expanded step 4 in the tx of DKA? What is the goal?
recheck glucose q hour
reduce glucose by 75 mg/dL/hr
What should you do in DKA if the glucose does NOT decrease by 10% after 1 hour?
give a 0.14 U/kg bolus regular insulin then resume normal rate
What should you do in DKA if the gluocse decreases faster than 75md/dL/hr?
decrease insulin drip by half.
What should you do in DKA when the glucose approaches 200mg/dL? What additional thing also needs to be done?
switch IV fluids to D5½ NS
decrease insulin dose to 0.02-0.05 U/kg/hr
q2hours CMP, check electrolytes, anion gap, VBG
Why is the IV fluid switched to D5½ NS once the glucose approaches 200?
to prevent hypoglycemia and cerebral edema
What are the 2 monitoring goals in a pt with DKA? What additional 2 things need to be monitored?
Goal: return all electrolytes to normal ranges and keep K+ between 3.3-5.2 mEq/dL
Goal: Reduce AG and improve acid-base balance
monitor: mental status and I&Os
What are the special circumstances in DKA if the pt has a pH less than 6.9?
pH < 6.9 - consider giving NaHCO3 in water with 20 mEq of K+ - repeat dosing every 2 hours until pH is > 7.0
What are the 2 types of CVA?
ischemic and hemorrhagic
What are the 2 types of hemorrhagic CVA?
Intracerebral
Subarachnoid
_____ with ____ with intracranial hemorrhage. What is a rare presentation?
Severe headache
N/V
seizures and syncope
How will a CVA present? **What is the super important hx question?
an acute neurologic deficit
Motor
Sensory
Coordination/balance/vertigo
Mood/behaviors
Altered mental status
**When was their last known normal?”
________ must be performed in all pt with suspected CVA
NIHSS Score
it is on MD calc
What is included in the dx work-up of a pt with a suspected stroke? Who do you need to consult? When? What is the disposition?
Consult neurology/tele-neurology
preferably before giving tPA if time allows
All patients will require admission preferably to a stroke unit or ICU
What is the goal timing for a brain CT WITHOUT contrast in a suspected CVA? What will the finding be in an ischemic stroke?
completed with in 25 minutes of arrival
CT will be normal in an ischemic stroke
What is the timing window for an acute hemorrhage to show on the CT?
Highly sensitive within 6 hours of onset to rule out/in acute hemorrhage
What is the goal O2 stat for a stroke? How should the pt be positioned?
above 94%
lie supine
in a CVA, want the pt to lie ______. What are the exceptions?
lie supine
elevate head 30° if increased ICP, aspiration risk or chronic CV/Pulm disease
If the pt is on an anticoagulation and having a hemorrhagic stroke, what should you do next?
Anticoagulation reversal
If the pt is having an intracerebral hemorrhage and BP is 150-220, what should you do? What agents are used? What is the goal BP?
acute (within 1 hour) lowering of BP to an optimal SBP goal of 140 mmHg
labetalol, nicardipine, clevidipine
SBP goal between 140-160 mmHg
If the pt is having an intracerebral hemorrhage and BP higher than 220, what should you do? What is the goal BP? What BP agents should you use?
aggressive reduction with continuous IV infusion
BP monitoring every 5 minutes
SBP goal between 140-160 mmHg
labetalol, nicardipine, clevidipine
What is the goal BP for a pt with a ischemic stroke getting tPA need to be? What agents?
BP goal of SBP ≤ 185 and DBP ≤ 110 before tPA can be administered
labetalol, nicardipine, clevidipine
What is the goal BP for a pt with a ischemic stroke NOT getting tPA need to be? What agents?
Do not treat unless SBP >220 or DBP >120 or signs of end-organ damage
labetalol, nicardipine, clevidipine
Are elevated trops a sign of end-organ damage?
YES!! elevated trops signifies heart is stressed
How do you determine if someone is eligible for tPA? **What are the inclusion criteria?
calculator on MD calc
**Inclusion criteria:
1. Clinical diagnosis of ischemic stroke causing measurable neurologic deficit
- Onset of symptoms within 4.5 hours of initiation of treatment
- Age ≥18 years
need to have all 3 to be eligible
Does tPA require informed consent? How is it administered? What are the monitoring requirements? What does the BP need to be?
YES!!
Infuse tPA over 60 minutes
Perform neuro checks q15m x 3 hours then q30 minutes x 6 hours
Keep BP < 180/105 mmHg
When is an endovascular mechanical thrombectomy indicated? What is the associated timing?
Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure
needs to be in a LARGE vessel
When will TIA symptoms typically resolve? What is the work-up?
within 1-2 hours
same as a stroke, tx is same as stroke
**What is the disposition of a TIA?
based on the presence of high risk features, admit if 1 or more are present
**need to know high risk feature!!
