AMS 1- SG Flashcards
Glasgow Coma Scale (GCS)
- 15
Best score
GCS
8 or lower
Comatose
GCS
3
Unresponsive
AMS is present in up to ___% of elderly hospitalized patients
- (elderly >__ years of age)
50%
- 65 yrs
3 origins of AMS
- Medical
- Neurologic
- Psychiatric
Other names of AMS
- ALOC
- Encephalopathy
- Confusion
- Delirium
- Acute confusional impairment
- Neurocognitive disorder (dementia)
- Organic brain syndrome
7 levels of consciousness
“A Cloudy Conscience Leaves Others Super Crabby”
- Alert
- Clouding of consciousness
- Confusional state
- Lethargic / Somnolent
- Obtunded
- Stuporous / Semicomatose
- Comatose
Which level of AMS/LOC?
- Awake & fully aware of surroundings
- Responds appropriately to normal stimuli
- Does not imply capacity to focus attention
Alert
Which level of AMS/LOC?
- Very mild form of altered mental status
- Inattention and reduced wakefulness
Clouding of consciousness
Which level of AMS/LOC?
- More profound deficit
- Disorientation, bewilderment, difficulty following commands
Confusional State
Which level of AMS/LOC?
- Not fully alert / drifts off to sleep when not stimulated
- Spontaneous movements decreased
- Awareness limited
- Unable to pay close attention, loses train of thought
- “confabulating”
Lethargic / Somnolent
Which AMS / LOC?
- Difficult to arouse & when aroused is confused
- Constant stimulation required to elicit minimal cooperation
Obtunded
Which AMS / LOC?
- Does not arouse spontaneously
- Requires persistent & vigorous stimulation
- When aroused, will moan/mumble
Stuporous / Semicomatose
Which AMS / LOC?
- Unarousable, unresponsive to stimuli (reflexes)
- GCS usually less than 8
Comatose
____ is common & associated w/ substantial morbidity for older people & often unrecognized
Delirium
Incidence of delirium is highest in which patients?
(up to 70%)
ICU patients
- Disturbance in attention / awareness
- Disturbance develops over a short period of time (hrs to days) and fluctuates during course of day
- Additional disturbance in cognition
DSM V for Delirium
7 Risk Factors for Delirium
- Age (over 65)
- Male
- Dementia
- Functional impairment in activities of daily living
- Medical comorbidities
- Hx of excessive ETOH use (associated w/ withdrawal)
- Sensory impairment (vision/hearing) so, have pt’s hearing aids/glasses available immediately after procedures/surgeries
“65 yr old male w/ dementia having a bad day bc of his comorbidities, so he drinks ETOH and has withdrawals, and he can’t hear or see anything”
- Which infections lead to Delirium?
- Which medications lead to Delirium?
- Urinary Respiratory (PNA)
- Meds: Opioids, Benzos, anticholinergics
When taking a hx for pt w/ Delirium, be sure to do a medication review (especially which 3 things?)
- Rx
- OTC
- ETOH
W/ delirium, ETOH withdrawal usually occurs ___ hours after their last drink. Can be as soon as ___ hours if the patient is a heavy drinker and their withdrawal sxs would include: ____.
- Usually 48 hours
- Soon as 24 hours
- Hallucinations
Do people w/ delirium from ETOH withdrawal usually experience hypothermia or hyperthermia?
Either
- When ordering labs for pt w/ delirium, what 3 things are you looking for?
- Which one thing does not cause delirium?
- Hypernatremia
- Hypoglycemia
- Hypercalcemia
- NOT: Hyperkalemia
When checking an ABG on a pt w/ delirium, what would you be looking for?
Hypercapnia
4 labs for Delirium
- CBC
- Electrolytes
- Renal function tests
- Liver function tests
Consider ordering what 3 things for delirium?
- Brain imaging
- EEG
- CSF
- When maintaining behavioral control in pts w/ Delirium, what should be avoided?
- Which 2 meds should only be used if they are absolutely necessary?
- Avoid restraints
- Small doses of Haloperidol or Quetiapine
Which drugs should be reduced/eliminated in pts w/ delirium?
- Alcohol
- Anticholinergics
- Some antidepressants
- Antihistamines
- Anticonvulsants
- Antiparkinsonian agents
- Antipsychotics
- Barbiturates
- Benzos
- H2 blockers
- Opioid analgesics
Delirium or Dementia?
- Memory impairment
- Progressive / insididious onset
Dementia
Delirium or Dementia?
- Memory Impairment
- Disturbance of consciousness
- Acute / Rapid onset
- Fluctuation of sxs during 24 hr period
Delirium
(everything except progressive/insidious onset)
- Hypoxemia
- Hypoglycemia (DM pts w/ insulin overdose)
- Sepsis
- Hypertensive encephalopathy
- Wernicke’s encephalopathy
- Overdose
- CNS infections / trauma
- Intracranial hemorrhage
- Epilepsy
Life threatening etiologies of AMS
- UTI
- PNA
Electrolyte abnormalities - Meds effect / interaction
- Medication withdrawal
- Psych illness
Common Conditions as etiologies of AMS
- Endocrine disease (thryoid/adrenal)
- Stroke w/o focal motor deficit
- CNS mass
- Dementia
“other” etiologies of AMS
AMS Mnemonics
AEIOU-TIPS
- Alcohol, acidosis
- Epilepsy, endocrine
- Infection
- Overdose, oxygen deprivation
- Uremia
- Trauma, tumor
- Insulin (hyper/hypoglycemia)
- Stroke, space occupying lesion
AMS mnemonic
DEMENTIA
- Drugs
- Electrolytes
- Metabolic
- Emotional (psych)
- Neurologic, nutritional
- Trauma, tumor, temp
- Infection
- Alcohol
AMS Mnemonic
MOVE STUPID
- Metabolic
- Oxygen (hypoxemia)
- Vascular
- Electrolyte, endocrine
- Seizure
- Tumor, trauma, temp, toxin
- Uremia
- Pscyhiatric
- Infection
- Drugs (withdrawal)
- What is the most common electrolyte / metabolic abnormality of AMS?
- What can result if this abnormality is corrected too quickly?
Hyponatremia
(profoundly low sodium, if corrected too quickly can result in demyelination of central pontine and can result in death)
Besides hyponatremia (MC abnormality of AMS), what else should be considered?
Hypercalcemia
3 pre-existing systemic diseases of AMS
- DM
- Thyroid
- Cirrhosis
6 Emotional/Psych disorders associated w/ AMS?
- Neurocognitive disorder
- Dementia
- Delirium
- Wernicke’s encephalopathy
- Conversion disorder
- Psychosis
Thiamine deficiency from ETOH abuse
Wernicke’s encephalopathy
What is usually the most helpful diagnostic study for AMS when assessing head trauma?
CT (need to assess spinal cord injury)
When performing a rectal exam when assessing a patient w/ AMS after head trauma,
- if the sphincter tone is intact, the injury is likely _____.
- if little or no tone, there may be ____
- Intracranial
- Coexisting spinal cord injury
- W/ hypothermia, skin temp is near __ F
- What 4 things associated w/ hypothermia from AMS?
- If temp is 92-86F, results in what 3 things?
- 91 F
- Peripheral vasoconstriction, shivering, cardiovascular changes, respiratory changes
- Apathy, lethargy, ataxia
Hyperthermia
-
Heat exhaustion: core temp may be normal or < ___F
- 3 signs of heat exhaustion
-
Heat stroke: core temp above ___F
- 4 signs of heat strroke
-
<106F
- Orthostatic hypotension
- Tachycardia
- Sweating
-
106F
- Same as heat exhaustion + CNS dysfunction
- High suspicion of infection in which 2 age groups?
- Elderly pts get which 2 infections?
- Infants get which infection?
- Pts may be _____.
- Need to identify and tx quickly!
- Very young or very old
- Elderly: UTI or PNA
- *Infants:** meningitis
- Febrile
- Produces a metabolic encephalopathy similar to that produced by ________.
- Acute intoxication of alcohol produces metabolic enc similar to that produced by sedative-hypnotic drugs.
Apart from “metabolic encephalopathy,” what are 4 other side effects of Acute Alcohol Intoxication?
- Peripheral vasodilation
- Tachycardia
- Hypotension
- Hypothermia (pt passes out in cold weather)
- Most mild signs / sxs of acute alcohol intoxication?
- Most severe signs / sxs of acute alcohol intoxication?
(BAL = blood alcohol level)
- Mild (20-50): Diminished fine motor coordination
- Severe (400): Respiratory depression
