Altered Mental Status + Toxicology Flashcards
range of consciousness
alert
lethargic or somnolent
obtunded
stuporous or semicomatose
comatose
what level of consciousness
awake and fully aware
responds appropriately
+/- ability to focus attention
alert
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
lethargic
what level of consciousness?
difficult to arouse, confused
stimulation required to elicit minimal cooperation
obtunded
what level of consciousness?
does not rouse spontaneously
requires vigorous stimulation with little response
when aroused will moan, mumble
stuporous
what level of consciousness?
unarousable unresponsiveness
coma
what grades coma severity according to three categories
glasgow coma scale
what three categories in glasgow coma scale
eye opening
motor responses
verbal responses
if you are dead, what do you score on GCS
3
GCS step 1: eye opening
what is a 4, 3, 2, and 1?
4 - spontaneous eye opening
3 - responds to speech
2 - responds to pain
1 - no response
GCS step 2L
motor response
what is 6, 5, 4, 3, 2, 1?
6 - obeys motor commands
5 - localizes motor demands
4 - withdrawals
3 - abnormal flavor responses
2 - extensor response
1 - no response
flexor response (score 3) - what kind of posturing
decorticate posturing
what is decorticate posturing?
flexion with adduction of arms and extension of legs (COR - hands over heart)
what does decorticare posturing indicate?
destructive lesion in corticospinal tract from cortex to upper midbrain
what is extensor posturing (score of 2 for motor movements)?
decerebrate posturing
what kind of posturing?
extension, adduction, and internal rotation of the arms and extension of legs
decerebrate
what is decerebrate posturing associated with
damage to corticospinal tract at level of brainstem (pons, upper medulla) - primative stuff
damage at brainstem
decerebrate posturing
damage at cortex to upper midbrain
decorticate posturing
GCS - verbal response
5, 4, 3, 2, 1
5 - oriented
4 - confused conversation (say wrong year when asked what year it is)
3 - inappropriate words
2 - incomprehensible sounds
1 - no response
GCS of 15 - means what
wide awake and appropriate
GCS of 3 means what
dead or deep coma
when is GCS most useful
trauma
GCS - lower number assoc with
worse prognosis
if GCS of 8 of 72 hours or longer - what does that mean
very poor prognosis
what do you do if GCS is 8 or less
INTUBATE - protect airway
Demenia DSM definition
sig cog impairment in at least one of the following:
learning and memory, language, executive function, complex attention, perceptual motor function, and social cognition
Major neurocognitive disorder DSM 5 criteria
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
5 key features of delirium
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
are focalized or lateralized neurologic findings characteristic of delirium
NOPE
visual or auditory hallucinations with delirium
visual
mortality ____ for a pt with a given medical condition plus delirium
doubles
delirium number 1 risk factor
underlying brain disease
other risk factors for delirium
80+
infection
polypharmacy
ETOH use
men
multiple medical issues
fractures
5 steps in evaluation of AMS
- ABCs
- Vitals, mental status (GCS), pupil size, skin temp
- pulse ox, cardiac monitoring
- complete hx and phys exam
- start interventions
what interventions should be started with AMS immediately
oxygen
glucose
EKG
place IV/draw labs
additional workup for AMS: what serology tests
electrolytes
creatinine
glucose
calcium
CBC
UA
pregnancy
diagnostic workups for AMS: EKG
if CAD history or over 50
dx workup for AMS: CXR
if resp symptoms or fever
dx workup for AMS: head CT
if focal neuro exam findings or hx of trauma
dx workup for AMS: ABG
hypoxic or metabolic acidosis (esp with COPD pts)
what other diagnostic work-up for AMS
TSH, folate, vit B12, blood alcohol, urine drug screen, specific drug levels
dx workup for AMS: lumbar punction
if meningitis/encephalitis are suspected
tx AMS
identify and tx underlying cause
in the mean time:
thiamine
dextrose - blood sugar is low
naloxone if narcotic overdose is possible
should you use physical restraints with AMS
last resort only
pharmacological restraint - low dose haldol (esp in older patients)
are benzos part of tx in undifferentiated AMS
avoided - rough symptoms for elderly
are cholinesterase inhibitors effective at prevention or treatment of delirium
nope
how long does it take delirium to fully resolve
weeks or months
questions to ask when toxins are considered
which toxin
how much
when
what was pt doing when he/she became ill
what four things can cause CNS stimulation and elevation of HR, BP, RR, and temp
anticholinergics
sympathomimetics
central hallucinogen agents
drug withdrawal
examples of anticholinergics
URI meds - dextromethoraphan
atropine
some antidepressants
examples of sympathomimetics
cocaine
meth
bath salts
epi/norepi
central hallucinogen agents exams
PCP
LSD
MDMA
drug withdrawal that can lead to CNS stimulation
ETOH
What things can cause physiologic depression?
ETOH + methanol + ethylene glycol intox
sedative-hyponotics
opiates
cholinergics
sympatholytics
depressed mental status and reduced HR, BP, RR, temp
physiologic depression
what is assoc with mixed physiologic effects
polydrug ODs, exposure to metabolic poisons, heavy metals, agents with multiple mechanisms of action
what drugs can cause mixed physiologic effects
metformin
sulfonylureas
aspirin
cyanide
iron
TCAs
mixing of street drugs
the _____ decontamination is performed, the _____ it is at preventing poison absorption
sooner
more effective
topical exposures - decontamination
copious water or saline irrigation
ways of enhanced elimination for decontamination
forced diuresis
urine ion trapping
hemodialysis
exchange transfusion
what is the cornerstone of toxicology tx
SUPPORTIVE CARE
antidotes may do what four things
prevent absorption
bind and neutralize poisons directly
antagonize end-organ effects
inhibit conversion to more toxic metabolites
when can toxicity recur with antidotes
when antidote is eliminated more rapidly
so repeated administration is needed
should you always use antidotes
give an example of your answer
NO
flumazenil for benzo reversal can precipitate seizures in chronic benzo users
antidote for acetaminophen
n-acetylcysteine
antidote for amitriptyline
sodium bicarb
antidote for anticholinergic
physostigmine
antidote for beta blockers
glucagon
antidote for benzos
flumazenil
antidote for calcium channel blockers
calcium
antidote for coumadine
vitamin K, FFP
antidote for cyanide
hydroxocobalamin
antidote for digoxin
digoxin antidote
antidote for heparin
protamine
antidote for hydroflouric acid
calcium
antidote for iron
desferrioxamine
antidote for methanol/ethylene glycol
ethanol
antidote for methemoglobin
methyline blue
antidote for opiates
naloxone
antidote for organophosphates
atropine, 2-PAM
antidote for salicylates
urine alkalization, dialysis
antidote for sulfonylureas
octreotide
opiods
benzos
cocaine
THC
barbituates
amphetamines
TCAs
buprenorphine
what test
urine drug screen
acetaminophen
salicylate
carboxyhemoglobin
digoxin
lithium
iron/lead/mercury
ethylene glycol
antiepileptic drugs
what test
serum screening
signs/symptoms that occur consistently as a result of a toxin
what is this
toxidrome
changes in _____ and _____ are part of toxidromes
changes in vital signs
end-organ manifestations
labs for ALL pts with AMD
pregnancy test
glucose
acetaminophen and salicylate testing
what am i describing?
clammy skin
vomiting/diarrhea
lots of eye/nose discharge
BRADYcardia
pinpoint pupils
cholinergic
cholinergic toxidrome caused by
organophosphate and carbamate insecticides, nerve agents (sarin), nicotine, pilocarpine, physostigmine, edrophonium, bethanechol, urecholine
DUMBELS: cholinergic toxidrome
Defecation
Urination
Muscle weakness
Bradycardia, bronchorrhea, bronchospasms
Emesis
Lacrimation
Salivation
SLUDGE and Killer Bs: cholinergic toxidrome
Salivation Lacrimation Urination Defecation GI pain Emesis
Bradycardia, bronchorrhea, bronchospasms
dx of cholinergic toxidrome
clinical
tx of cholinergic toxidrome
aggressive decontamination ASAP
atropine for symptom control
2-PAM - antidote
reactivates cholinesterase
2-PAM
blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone
what toxidrome
anticholinergic
causes of anticholinergic toxidrome
antihistamines (URI drugs)
Jimson weed
Scopalamine
symptoms of anticholinergic toxidrome
hyperthermia
dry, flushed skin
dilated pupils
agitation, hallucinations, delirium
tachycardia
HNT
urinary retention
decreased bowel sounds
(can’t pee, can’t poop)
earliest and most reliable signs of anticholinergic toxidrome
tachycardia
ALSO NON-SPECIFIC
dx of anticholinergic poisoning
clinical
tx of anticholinergic poisoning
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
hyperthermia
tachycardia
HTN
diaphoresis
agitation, hallucinations, paranoia
dilated pupils
seizures
waht toxidrome
sympathomimetic
difference between anticholinergic and sympathomimetic toxidromes?
anticholinergic - DRY SKIN; hypoactive bowel sounds
SYMPATHOMIMETICS - DIAPHORESIS (WET SKIN); hyperactive bowel sounds; seizures too! more common than with anticholinergics
causes of sympathomimetic toxidromes
cocaine
amphetamines
ephedrine
pseudoephedrine
bath salts
theophylline
caffeine
mimics fight or flight
alcohol withdrawal also can mimic this
what toxidrome?
sympathomimetic
tx of sympathomimetic toxidrome
benzos
supportive care
hypothermia
bradycardia
hypotension
bradypnea/apnea
pulm edema
CNS depression, coma
miosis
what toxidrome
opioid
flash pulm edema with normal sized heart - think what
heroin
tx of opioid
naloxone
duration of action is 45 min so may need to repeat dosing
for chronic narcotic users - what do you do?
start with lower doses (.4 mg) to avoid precipitating withdrawal
what toxidrome
hypothermia
vitals normal
bradypena/apnea
CNS depression and coma
hyporeflexia
variavle pupils
sedative-hypnotic
causes of sedative hypnotic toxidrome
benzos, barbituates, GHB, alcohols, flunitrazepam (roofie in europe/mexico)
tx of sedative-hyponotix toxidrome
supportive care
rarely flumazenil
why is flumazenil not used in sedative-hypnotic toxidrome tx
induces seizures in chronic benzo users
