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Foundations II-Neurology > AMS > Flashcards

AMS Flashcards

1
Q

Other names for AMS?

A

ALOC, encephalopathy, confusion, delirium, acute cognitive impairment, neurocognitive disorder, organic brain syndrome

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2
Q

What is meant by level of consciousness? What is it impaired by?

A

measurement of response to stimuli and arrousability

impairment caused by bi cerebral dysfunction or within the RAS

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3
Q

Range of LOC?

A

Alert

Lethargic/somnolent

Obtunded

Stuporous/semi comatose

Comatose

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4
Q

Does alert imply capacity to focus attention?

A

NO

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5
Q

Describe lethargic or somnolent

A

not fully alert and drifts off to sleep when not stimulated

spontaneous movements decreased

awareness limited

unable to pay close attention

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6
Q

Describe obtunded

A

dif. to arouse and confused when aroused

constant stimulation req. to elicit minimal cooperation

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7
Q

Describe Stuporous/semicomatous

A

dose not rouse spontaneously, requires persistent and vigorous stimulation

when aroused will moan or mumble

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8
Q

Typical GSC for pts in Comatose state?

A

usually less than 8

if less than 8 then intubate

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9
Q

Persistence of delirium leads to…

A

poor long term outcomes

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10
Q

What is delirium?

A

disturbance in attention and awareness

develops over a short period of time

+ disturbances in cognition

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11
Q

Risk factors for delirium?

A

age, male gender, dementia, func. impairments in ADLs, medical comorbidities, hx of excessive ETOH use, sensory impairment (vision, hearing)

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12
Q

What can precipitate delirium?

A

Acute card/pulm events, bed rest, drug withdrawal, fecal impaction, fluid/electrolyte disturbances, indwelling devices, infx, meds, restraints, severe anemia, uncontrolled pain, urinary retention

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13
Q

How do we manage delirium?

A
  1. Prevention- avoid causes/precipitating factors
  2. Identify & tx reversible contributors
  3. Maintain behavioral control -sitter/fam, sleep/wake cycles, reorientation, reassurance, music, AVOID restraints
  4. Prevent complications
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14
Q

What can you give to maintain behavioral control if absolutely necessary?

A

Haloperidol

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15
Q

Drugs to reduce/eliminate in delirium pts?

A

alcohol, anticholinergics, anticonvulsants, antipsychotics, barbiturates, benzos, H2 blocking agents, opioids

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16
Q

Presentation of AMS?

A

confusion, lethargy, memory impairment, personality change, combativeness, agitation, etc.

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17
Q

Common causes of AMS?

A

AEIOU TIPS

alcohol and other toxins

endocrine and environmental factors

Insulin poisoning

Oxygen deprivation

uremia

trauma

infection

psychiatric causes

space occupying lesions

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18
Q

What is the most common electrolyte abnormality in AMS?

A

hyponatremia

also consider hypercalcemia

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19
Q

If pt has AMS secondary to head trauma what do you need to assess for?

A

spinal cord injury –> protect the spine

  • CT head/c-spine
  • rectal exam
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20
Q

Skin temp in hypothermia? physiologic responses?

A

near 91 F

peripheral vasoconstriction, shivering, AMS, CV and res changes

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21
Q

What is heat exhaustion? signs?

A

core temp may be normal or <106

orthostatic hypotension, tachycardia, sweating

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22
Q

What is a heat stroke?

A

core temp above 106F

same signs as heat exhaustion (orthostatic hypotension, tachycardia, sweating)

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23
Q

What should you think of as cause of AMS in very young or very old until proven otherwise?

A

Infection!

elderly: UTI, pna
infants: meningitis

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24
Q

What should you assess first in a pt presenting with AMS?

A

ABC
-airway, breathing, circulation

then:
VS, mental status, pupil size, skin temp

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25
Tx of AMS
Identify and tx underlying cause + SNOT cocktail - Sugar (Glucose) - Naloxone (Narcan) - Oxygen - Thiamine (given prior to glucose to avoid inducing Wernicke-Korsakoff syndrome)
26
What drugs are associated with Physiologic excitation? (CNS stimulation and increased HR, BP, RR, temp)
anticholinergics, cocaine, meth, bath salts, PCP, ETOH withdrawal
27
What drugs are associated with physiologic depression? (depressed MS and decreased HR, BP, RR and temp)
ETOH, sedatives-hypotonics, cholinergics, pain meds, benzos
28
OD of which drugs can you mixed physiologic effects?
polydrug OD, heavy metals, Metformin, sulfonylurea, ASA, cyanide, iron, TCAs
29
Which toxins produce a fruity odor? Rotten egg odor?
Isopropanol, ETOH, DKA hydrogen sulfide
30
What labs should you order in a pt with AMS?
``` CBC electrolytes with anion gap BUN Creatinine Glucose LFTs HCG UDS ```
31
Reasons for a high anion gap?
MUDPILES: ``` Methanol Uremia DKA Paraldehyde Infection Lactic Acidosis Ethylene Glycol Salicylates ```
32
What is a toxidrome?
a clinical syndrome, constellation of signs//sxs that suggest a specific class of poisoning
33
Which toxidromes cause mydriasis?
pupillary dilation: - sympathomimetic - anticholinergic - hallucinogenic (usually) - serotonin syndrome
34
Which toxidromes cause miosis?
pupillary constriction: - opioids - sedative-hypotonic (usually) - cholinergic
35
What are some examples of sympathomimetics? Signs/sxs?
Amphetamines and cocaine - psychomotor agitation, restlessness, anxiety - piloerection (goosebumps), mydrasis, diaphoresis, tachycardia, HTN, hyperthermia
36
What are some anticholinergics? sxs of anticholinergic toxicity?
antihistamines, TCAs, phenothiazines Hot as a hare > fever Blind as a bat > mydriasis Dry as a bone > dry mm, urinary retention Red as a beet > flushing Mad as a hatter > psychosis -Prolonged QT
37
Risk associated with long QT interval? Tx?
Torsades de pointes give Mg
38
Tx for anticholinergic toxicity?
alkalization (NaHCO3 for polycyclic antidepressant poisoning and for conduction abnormalities
39
Sxs of cholinergic toxicity?
SLUDGE + killer B's: ``` Salivation Lacrimation Urination Defecation GI pain Emesis Bradycardia, bronchorrhea, bronchospasms ```
40
Why is OD of Acetaminophen so dangerous?
It is metabolized to a toxic intermediate N-acetyl benzoquinoemine (NAPQI) which is then detoxified by glutathione potentially fatal secondary to acute hepatic failure
41
Sxs of Acetaminophen OD?
usually asxs during first 24 hours +/- N/V then S/S of liver injury
42
Interventions for Acetaminophen OD?
activated charcoal, N-actetylcysteine, liver transplant
43
Ex. of salicylates? sxs ?
ASA, oil of wintergreen (methyl salicylate), Pepto Bismol AMS, respiratory alkalosis, metabolic acidosis, tinnitus, tachycardia, tachypnea,diaphoresis, N/V, fever potentially fatal secondary to pulmonary edema or cardiopulmonary arrest
44
Interventions for salicylate OD?
activated charcoal, hydration, hemodialysis
45
Ex. of hypoglycemic agents? Sxs?
sulfonylureas, insulin AMS, diaphoresis, tachycardia, increased BP, slurred speech potentially fatal secondary to seizures
46
Interventions for hypoglycemic agents OD?
glucose, freq. BS monitoring
47
Sources of methanol and ethylene glycol?
wood alcohol, antifreeze, washer fluid, paint stripper rapidly and completely absorbed after ingestion
48
Sxs of Methanol and ethylene glycol OD?
like ETOH intoxication blurred vision and blindness (methanol) flank pain and hematuria (ethylene glycol) - calcium oxalate crystals in the urine are characteristic potentially fatal 2/2 profound metabolic acidosis, renal failure and seizures
49
Interventions for methanol and ethylene glycol ingestion?
Fomepizole, thiamine, folic acid or pyridoxine, ethanol, sodium bicarb, HD
50
What are synthetic cannabinoids?
analogs of natural cannabinoids that are chemically synthesized "incense", "spice", "K2" "chill out" will NOT be detected on UDS
51
sxs of synthetic cannabinoids?
tachycardia, slurred speech, conjunctival injection, nystagmus, N/V, ataxia, AMS< hallucinations, paranoia, seizures
52
Tx for synthetic cannabinoids OD?
supportive care benzos
53
What are bath salts? sxs?
a cathinone, which is a beta ketone amphetamine analog -synthetic form AMS, tachycardia, increased BP, fever, mydriasis, agitation, anxiety, seizures, hallucination, paranoia
54
Interventions for bath salts OD?
supportive care, benzos
55
Sxs of significant opioid OD?
depressed consciousness and eventually coma miosis hypotension and bradycardia > cardiopulmonary arrest
56
S/S of alcohol withdrawal? Tx?
autonomic hyperactivity: diaphoresis, tachycardia tremors, insomnia, hallucination, N/V, anxiety, seizures, loss of appetite Tx: benzos
57
What is delirium tremens? Tx?
due to alcohol withdrawal > med emergency due to extreme autonomic hyperactivity with delirium Tx: IVF, thiamine, benzodiazepines
58
What is wernicke's encephalopathy? What is it associated with?
med emergency caused by acute thiamine deficiency sxs: ophthalmoplegia, ataxia and confusion Assoc. with: alcoholism and malnutrition
59
Tx of wernicke's encephalopathy?
thiamine and multivitamin failure to recognize and tx may result in death or permanent neuro impairment
60
When can gastric lavage be used for ingestion?
if ingestion occurred less than 60 mins earlier and the airway is protected
61
Characterisitics of CO? When should you suspect poisoning?
colorless, oderless, tasteless, non-irritating whenever a pt has suffered burns in a poorly ventilated area DONT rely on pulse ox, carboxyhemoglobin causes it to be overestimated
62
Sxs of CO poisoning?
HA, dizziness, dyspnea, fatigue, CP, confusion cherry red skin coloring
63
Common source for poisoning in AZ? Tx?
recreational boating, esp. houseboats All pts on 100% O2, some should receive hyperbaric oxygen
64
Antidote for Acetaminophen? Anticholinersterases?
N acetyl cysteine Atropine
65
Antidote for Benzodiazepines? beta blockers?
Flumazenil but may cause seizures Glucagon
66
Antidote for CCBs? CO? Opioids?
Calcium Oxygen Narcan
67
What is a concussion?
A complex pathophysiological process affecting the brain, induced by traumatic mechanical forces rapid onset of neuro dysfunc. that resolves spontaneously
68
Typical mechanism for concussion?
coup (blow) coutre-coup (counter blow)
69
S/S of concussion?
+/- LOC (usually none) confusion memory loss visual disturbance vertigo/impaired balance HA
70
Post concussive sxs?
Chronic HA Short-term memory difficulties Fatigue Difficulty sleeping Personality changes (irritability, mood swings) Sensitivity to light/noise (Symptoms typically resolve in days to months)
71
How do we dx a concussion?
clinically! Head CT usually NOT recommended -do neuroimaging if LOC or GCS <15 new lab testing: brain trauma indicator- measures levels of proteins UCH-L1 and GFAP
72
Concussion tx?
rest and acetaminophen for HA
73
When can pts return to play after concussion?
not until all sxs are gone and no meds are required
74
What is an epidural hematoma?
accumulation of blood in the potential space btwn dura and bone intracranial EDH require immediate surgical intervention
75
pathophys of EDH
results from linear contact force to skull that causes seperation of periosteal dura from bone w/ disruption of the vessels btwn due to shearing stress
76
What are some causes of EDH?
trauma, LP,, anticoagulation, cancer, vascular malformation, disk herniation, valsalva maneuver, etc.
77
EDH presentation?
suspect in any head trauma sxs: ALOC, HA, N/V, seizures, focal neuro deficits spinal EDH: weakness, sensory deficits, alteration in reflexes, alteration in bladder or anal sphincter tone
78
EDH physical exam?
eval for: - skull fx, hematoma - raccoon eyes or battle sign- thick basilar fx -hemotypanum - GCS - decerebrate and decorticate posturing - weakness - oculocephalic reflex (Doll's eyes) - anisocoria
79
What are the 3 areas evaluated in a GCS score?
eye opening verbal motor
80
What are some common CNS herniations? Presentations?
Subfalcine: HA contralateral leg weakness. Transtentorial: oculomotor (CN III) paresis (ipsilateral dilated pupil, abnl EOM’s), contralateral hemiparesis. Tonsillar: Obtundation
81
A brain herniation is...
life threatening! increased ICP may cause cushing's syndrome
82
Work up for EDH?
CBC coags serum chemistry toxicology screen type and screen Imaging: skull xray, CT MRI, myelography
83
What does an EDH look like on CT?
whitened area on edge of skull "white ain't right" looks like lemon
84
EDH tx?
emergency decompression with placement of burr hole to decrease ICP if neurosurg is not immediately available Surg: crainotomy or laminectomy > evacuation of hemotoma elevate head of bed at 30 deg +/- coagulopathy: fresh frozen plasma, K+ Osmotic diuretics- for those with elevated ICP Acetaminophen for fever Anticonvulsants as propylaxis
85
Where should a burr hole be placed for pts that demonstrate signs of rapid decompensation?
on the side of the dilating pupil
86
What can you give to spinal epidural pts when cord is compressed?
high dose methylprednisolone
87
What is a subdural hematoma?
Collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane MC type of traumatic intracranial mass lesion can be acute, subacute or chronic
88
Usual mechanism for subdural hematoma?
coup/contra-coup injury to brain small subdurals will resorb spontaneously
89
subdural hematoma presentation?
acute: varies, pts often comatose Chronic: usually insidious and in those > 40 y/o sxs: ALOC, HA, dif. w/ gait, cognitive dysfunc, personality change
90
Work up for subdural hematoma?
Emergent non con CT head consult neurosurg blood work
91
When should you repeat imaging in suspected SDH?
if GCS worsens by 2 or more points
92
Tx for acute SDH?
ABCs osmotic diuretics surg decompression admit to ICU

Foundations II-Neurology (9 decks)

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