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Surgery and Emergency Med > Altered Mental Status + Toxicology > Flashcards

Altered Mental Status + Toxicology Flashcards

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1
Q

range of consciousness

A

alert

lethargic or somnolent

obtunded

stuporous or semicomatose

comatose

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2
Q

what level of consciousness

awake and fully aware

responds appropriately

+/- ability to focus attention

A

alert

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3
Q

what level of consciousness?

not fully alert and drifts off to sleep with not stimulated

spontaneous movements decreased

awareness limited

unable to pay close attention, loses train of thought constantly and consistently

A

lethargic

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4
Q

what level of consciousness?

difficult to arouse, confused

stimulation required to elicit minimal cooperation

A

obtunded

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5
Q

what level of consciousness?

does not rouse spontaneously

requires vigorous stimulation with little response

when aroused will moan, mumble

A

stuporous

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6
Q

what level of consciousness?

unarousable unresponsiveness

A

coma

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7
Q

what grades coma severity according to three categories

A

glasgow coma scale

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8
Q

what three categories in glasgow coma scale

A

eye opening

motor responses

verbal responses

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9
Q

if you are dead, what do you score on GCS

A

3

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10
Q

GCS step 1: eye opening

what is a 4, 3, 2, and 1?

A

4 - spontaneous eye opening

3 - responds to speech

2 - responds to pain

1 - no response

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11
Q

GCS step 2L
motor response

what is 6, 5, 4, 3, 2, 1?

A

6 - obeys motor commands

5 - localizes motor demands

4 - withdrawals

3 - abnormal flavor responses

2 - extensor response

1 - no response

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12
Q

flexor response (score 3) - what kind of posturing

A

decorticate posturing

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13
Q

what is decorticate posturing?

A

flexion with adduction of arms and extension of legs (COR - hands over heart)

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14
Q

what does decorticare posturing indicate?

A

destructive lesion in corticospinal tract from cortex to upper midbrain

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15
Q

what is extensor posturing (score of 2 for motor movements)?

A

decerebrate posturing

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16
Q

what kind of posturing?

extension, adduction, and internal rotation of the arms and extension of legs

A

decerebrate

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17
Q

what is decerebrate posturing associated with

A

damage to corticospinal tract at level of brainstem (pons, upper medulla) - primative stuff

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18
Q

damage at brainstem

A

decerebrate posturing

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19
Q

damage at cortex to upper midbrain

A

decorticate posturing

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20
Q

GCS - verbal response

5, 4, 3, 2, 1

A

5 - oriented

4 - confused conversation (say wrong year when asked what year it is)

3 - inappropriate words

2 - incomprehensible sounds

1 - no response

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21
Q

GCS of 15 - means what

A

wide awake and appropriate

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22
Q

GCS of 3 means what

A

dead or deep coma

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23
Q

when is GCS most useful

A

trauma

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24
Q

GCS - lower number assoc with

A

worse prognosis

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25
Q

if GCS of 8 of 72 hours or longer - what does that mean

A

very poor prognosis

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26
Q

what do you do if GCS is 8 or less

A

INTUBATE - protect airway

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27
Q

Demenia DSM definition

A

sig cog impairment in at least one of the following:

learning and memory, language, executive function, complex attention, perceptual motor function, and social cognition

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28
Q

Major neurocognitive disorder DSM 5 criteria

A

cog decline in 1+ domains

impairment is acquired and represent sig decline from previous functioning

interferes with independence

does not occur exclusively in context of delirium

not better explained by another mental disorder

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29
Q

5 key features of delirium

A

disturbance in attention and awareness

develops over short period of time

fluctuates throughout day

additional disturbance in cognition

not better explained by other neurocog disorder

disturbance is caused by medical condition, substance intox or withdrawal, or med side effect

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30
Q

are focalized or lateralized neurologic findings characteristic of delirium

A

NOPE

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31
Q

visual or auditory hallucinations with delirium

A

visual

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32
Q

mortality ____ for a pt with a given medical condition plus delirium

A

doubles

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33
Q

delirium number 1 risk factor

A

underlying brain disease

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34
Q

other risk factors for delirium

A

80+

infection

polypharmacy

ETOH use

men

multiple medical issues

fractures

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35
Q

5 steps in evaluation of AMS

A
  1. ABCs
  2. Vitals, mental status (GCS), pupil size, skin temp
  3. pulse ox, cardiac monitoring
  4. complete hx and phys exam
  5. start interventions
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36
Q

what interventions should be started with AMS immediately

A

oxygen

glucose

EKG

place IV/draw labs

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37
Q

additional workup for AMS: what serology tests

A

electrolytes

creatinine

glucose

calcium

CBC

UA

pregnancy

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38
Q

diagnostic workups for AMS: EKG

A

if CAD history or over 50

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39
Q

dx workup for AMS: CXR

A

if resp symptoms or fever

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40
Q

dx workup for AMS: head CT

A

if focal neuro exam findings or hx of trauma

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41
Q

dx workup for AMS: ABG

A

hypoxic or metabolic acidosis (esp with COPD pts)

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42
Q

what other diagnostic work-up for AMS

A

TSH, folate, vit B12, blood alcohol, urine drug screen, specific drug levels

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43
Q

dx workup for AMS: lumbar punction

A

if meningitis/encephalitis are suspected

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44
Q

tx AMS

A

identify and tx underlying cause

in the mean time:

thiamine

dextrose - blood sugar is low

naloxone if narcotic overdose is possible

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45
Q

should you use physical restraints with AMS

A

last resort only

pharmacological restraint - low dose haldol (esp in older patients)

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46
Q

are benzos part of tx in undifferentiated AMS

A

avoided - rough symptoms for elderly

47
Q

are cholinesterase inhibitors effective at prevention or treatment of delirium

A

nope

48
Q

how long does it take delirium to fully resolve

A

weeks or months

49
Q

questions to ask when toxins are considered

A

which toxin

how much

when

what was pt doing when he/she became ill

50
Q

what four things can cause CNS stimulation and elevation of HR, BP, RR, and temp

A

anticholinergics

sympathomimetics

central hallucinogen agents

drug withdrawal

51
Q

examples of anticholinergics

A

URI meds - dextromethoraphan

atropine

some antidepressants

52
Q

examples of sympathomimetics

A

cocaine

meth

bath salts

epi/norepi

53
Q

central hallucinogen agents exams

A

PCP

LSD

MDMA

54
Q

drug withdrawal that can lead to CNS stimulation

A

ETOH

55
Q

What things can cause physiologic depression?

A

ETOH + methanol + ethylene glycol intox

sedative-hyponotics

opiates

cholinergics

sympatholytics

56
Q

depressed mental status and reduced HR, BP, RR, temp

A

physiologic depression

57
Q

what is assoc with mixed physiologic effects

A

polydrug ODs, exposure to metabolic poisons, heavy metals, agents with multiple mechanisms of action

58
Q

what drugs can cause mixed physiologic effects

A

metformin

sulfonylureas

aspirin

cyanide

iron

TCAs

mixing of street drugs

59
Q

the _____ decontamination is performed, the _____ it is at preventing poison absorption

A

sooner

more effective

60
Q

topical exposures - decontamination

A

copious water or saline irrigation

61
Q

ways of enhanced elimination for decontamination

A

forced diuresis

urine ion trapping

hemodialysis

exchange transfusion

62
Q

what is the cornerstone of toxicology tx

A

SUPPORTIVE CARE

63
Q

antidotes may do what four things

A

prevent absorption

bind and neutralize poisons directly

antagonize end-organ effects

inhibit conversion to more toxic metabolites

64
Q

when can toxicity recur with antidotes

A

when antidote is eliminated more rapidly

so repeated administration is needed

65
Q

should you always use antidotes

give an example of your answer

A

NO

flumazenil for benzo reversal can precipitate seizures in chronic benzo users

66
Q

antidote for acetaminophen

A

n-acetylcysteine

67
Q

antidote for amitriptyline

A

sodium bicarb

68
Q

antidote for anticholinergic

A

physostigmine

69
Q

antidote for beta blockers

A

glucagon

70
Q

antidote for benzos

A

flumazenil

71
Q

antidote for calcium channel blockers

A

calcium

72
Q

antidote for coumadine

A

vitamin K, FFP

73
Q

antidote for cyanide

A

hydroxocobalamin

74
Q

antidote for digoxin

A

digoxin antidote

75
Q

antidote for heparin

A

protamine

76
Q

antidote for hydroflouric acid

A

calcium

77
Q

antidote for iron

A

desferrioxamine

78
Q

antidote for methanol/ethylene glycol

A

ethanol

79
Q

antidote for methemoglobin

A

methyline blue

80
Q

antidote for opiates

A

naloxone

81
Q

antidote for organophosphates

A

atropine, 2-PAM

82
Q

antidote for salicylates

A

urine alkalization, dialysis

83
Q

antidote for sulfonylureas

A

octreotide

84
Q

opiods

benzos

cocaine

THC

barbituates

amphetamines

TCAs

buprenorphine

what test

A

urine drug screen

85
Q

acetaminophen

salicylate

carboxyhemoglobin

digoxin

lithium

iron/lead/mercury

ethylene glycol

antiepileptic drugs

what test

A

serum screening

86
Q

signs/symptoms that occur consistently as a result of a toxin

what is this

A

toxidrome

87
Q

changes in _____ and _____ are part of toxidromes

A

changes in vital signs

end-organ manifestations

88
Q

labs for ALL pts with AMD

A

pregnancy test

glucose

acetaminophen and salicylate testing

89
Q

what am i describing?

clammy skin

vomiting/diarrhea

lots of eye/nose discharge

BRADYcardia

pinpoint pupils

A

cholinergic

90
Q

cholinergic toxidrome caused by

A

organophosphate and carbamate insecticides, nerve agents (sarin), nicotine, pilocarpine, physostigmine, edrophonium, bethanechol, urecholine

91
Q

DUMBELS: cholinergic toxidrome

A

Defecation

Urination

Muscle weakness

Bradycardia, bronchorrhea, bronchospasms

Emesis

Lacrimation

Salivation

92
Q

SLUDGE and Killer Bs: cholinergic toxidrome

A 
Salivation
Lacrimation
Urination
Defecation
GI pain
Emesis

Bradycardia, bronchorrhea, bronchospasms

93
Q

dx of cholinergic toxidrome

A

clinical

94
Q

tx of cholinergic toxidrome

A

aggressive decontamination ASAP

atropine for symptom control

2-PAM - antidote

95
Q

reactivates cholinesterase

A

2-PAM

96
Q

blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone

what toxidrome

A

anticholinergic

97
Q

causes of anticholinergic toxidrome

A

antihistamines (URI drugs)

Jimson weed

Scopalamine

98
Q

symptoms of anticholinergic toxidrome

A

hyperthermia

dry, flushed skin

dilated pupils

agitation, hallucinations, delirium

tachycardia

HNT

urinary retention

decreased bowel sounds

(can’t pee, can’t poop)

99
Q

earliest and most reliable signs of anticholinergic toxidrome

A

tachycardia

ALSO NON-SPECIFIC

100
Q

dx of anticholinergic poisoning

A

clinical

101
Q

tx of anticholinergic poisoning

A

control agitation with benzos

consider activated charcoal if recent (MUST have normal mental status to protect airway)

physostigmine - antidote - should be considered in mod/severe poisoning

102
Q

hyperthermia

tachycardia

HTN

diaphoresis

agitation, hallucinations, paranoia

dilated pupils

seizures

waht toxidrome

A

sympathomimetic

103
Q

difference between anticholinergic and sympathomimetic toxidromes?

A

anticholinergic - DRY SKIN; hypoactive bowel sounds

SYMPATHOMIMETICS - DIAPHORESIS (WET SKIN); hyperactive bowel sounds; seizures too! more common than with anticholinergics

104
Q

causes of sympathomimetic toxidromes

A

cocaine

amphetamines

ephedrine

pseudoephedrine

bath salts

theophylline

caffeine

105
Q

mimics fight or flight

alcohol withdrawal also can mimic this

what toxidrome?

A

sympathomimetic

106
Q

tx of sympathomimetic toxidrome

A

benzos

supportive care

107
Q

hypothermia

bradycardia

hypotension

bradypnea/apnea

pulm edema

CNS depression, coma

miosis

what toxidrome

A

opioid

108
Q

flash pulm edema with normal sized heart - think what

A

heroin

109
Q

tx of opioid

A

naloxone

duration of action is 45 min so may need to repeat dosing

110
Q

for chronic narcotic users - what do you do?

A

start with lower doses (.4 mg) to avoid precipitating withdrawal

111
Q

what toxidrome

hypothermia

vitals normal

bradypena/apnea

CNS depression and coma

hyporeflexia

variavle pupils

A

sedative-hypnotic

112
Q

causes of sedative hypnotic toxidrome

A

benzos, barbituates, GHB, alcohols, flunitrazepam (roofie in europe/mexico)

113
Q

tx of sedative-hyponotix toxidrome

A

supportive care

rarely flumazenil

114
Q

why is flumazenil not used in sedative-hypnotic toxidrome tx

A

induces seizures in chronic benzo users

Surgery and Emergency Med (6 decks)

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