AMS Flashcards
What does AOx4 mean
Alert: LOC and response to stimuli
Oriented: to person, place, and time +/- situation
If LOC is impaired, what is it due to
bilateral cerebral dysfunciton (oriented) OR
reticular activating system (Alert)
What are the levels of consciousness
Alert Lethargic/somnolent obtunded stuprose coma
What is delerium
Acute (hr-day) disturbance in attention and cognitive disturbance that is a direct physiological consequence of another medical condition
Delerium RF include
Age male dementia Hx high alcohol consumption sensory impairments
What can cause delerium
Infection Withdrawal Acute vasculae Trauma CNS lesion Hypoxia Deficiency of vitamins Endocrine Acute metabolic Toxins Heavy metals (also fecal impaction, bed rest)
Effective delerium management should include
Prevention: avoid causes
ID & TX: infection, pain, fluid balance, sensory deprivation
Maintain behavior: sitter, reorient, reassure, music (NO RESTRAINTS)
Prevent complication: falls, malnutrition, pressure ulcers
What med can be used to maintain control
IF necessary, Haloperidol
*black box- increase mortality in elderly with dementia
What should you avoid to decrease risk of delerium
alcohol antipsychotics benzos opioids anticholinergics H2 blockers (ppi)
How does AMS present
confusion, lethargy, inattention, agitation, impulsivity, delusions, hallucination, sedation, change in behavior or personality
Causes of dementia include
Drugs Electrolytes (Hyponatremia) Metabolic Emotional/psych Neuro/nutrition Trauma, tumor, temp Infection Alcohol
Hypercalcemia is
cancer intil proven otherwise
When finding metabolic causes, look for
DM
thyroid disease
cirrhosis
Neuro Sx in AMS include
dysphasia
dysarthria
unilateral facial droop and decreased strength
What are trauma, temp, and tumor signs
Concussion (protect Spine with c collar)
CT Head and c spine
rectal exam
What can a rectal exam tell you
Sphincter intact= intracranial etiology
no rectal tone= spinal cord injury
What is hypothermia
skin <91 = peripheral vasoconstriction, shivering, AMS, changes in cardiac and pulmonary
86-92 = apathy, lethargy, ataxia
What is heat exhaustion
core temp 106 or below = orthostatic hypotension, tachy, diaphoresis
What is heat stroke
> 106 degrees = tachy, diaphoresis, orthostatic hypotension AND CNS dysfunction
What infections are common in age extremes
elderly: UTI, PNA
infant: meningitis
(may not be febrile)
Acute intoxication causes
metabolic encephalopathy similar to sedative hypnotics
Tachycardia + hypotension + hypothermia
(BAL 300= coma)
When do you attribute AMS to psych causes
when you have r/o stroke, mass lesion, confusion, and delerium
How do you evaluate AMS
ABC (and glucose)- vitals, mental status, pupil size, skin temp, HR, O2
Start interventions
Then complete H&P to determine cause
How do you treat AMS
ID cause, Treat cause in the meantime; SNOT cocktail Sugar Naloxone (narcan) Oxygen Thiamine (give before glucose)
What is poisoning
predictable, dose dependent effects with a harmful agent
(usually accidental in kids 1-5)- intentional in adults
What are the MCC of toxic exposures
accidental ingestion (kids) accidental OD (elderly) intentional OD (suicide) secondary to psych disorder
History “matters” when determining cause
Material inhaled, ingested, or absorbed Amount taken Time Taken Emesis Reason S/Sx
Working in a garage often causes
CO poisoning
Applying chemicals to crops often causes
organophosphate poisoning
PE for poisoning will show 1 of two effects
Psychologic excitation (high HR, BP, RR, T) Physiologic depression (low HR, BP, RR, T)
What causes physiologic excitation
Anticholinergics Sympathomimetics Central hallucinogens Drug withdrawal (coke, meth, bath salts, PCP, LSD)
What causes physiologic depression
EtOH Sedative hypnotics Opiates Cholinergics Sympatholytics Toxic alcohols Ethylene Glycol (organophosphates, benzos, pain meds, methanol)
What will show mixed physiologic effects
Polydrug OD Metabolic poisons Heavy metals TCA (metformin, sulfonylurea, ASA, cyanide, iron)
What 2 physical exam findings can tell you a lot
pupil size, mydriatic or miotic
EOM’s, nystagmus
What labs should you get for diagnosis
CBC Anion gap and MUDPILES BUN, CR Glucose LFT B-HCG
What shows up on a urine drug screen
opioids benzo coke thc barbituates amphetamines TCA buprenorphine
What do you need a serum screening for
APAP ASA digoxin lithium valporic acid iron, lead, mercury
What is a toxidrome
clinical syndrome essential to recognize poison pattern (s/Sx of a certain class)
What is general therapy for all poisoning
ABC Gastric lavage (before activated charcoal if ingestion <60 min prior and airway is protected)
When would you preform hemodialysis for poison therapy
amphetamines lithium methanol ASA theophylline phenobarbital ethylene glycol
How do you treat different poisons
inhaled: Oxygen
Contaminated eyes: irrigation
Contaminated skin: water and dilute soap
Ingested: gastric lavage (NGT, OGT, PO charcoal)
What poison control numbers should you call
American Association of Poison Control Centers (1.800.222.1222)
Banner Poison Control Center (602.253.3334)
What is a concussion
traumatic biomechanical force (+/- head trauma) causing rapid onset neuro dysfunction that resolves spontaneously
+/- LOC, no imaging abnormalities
Who is most likely to sustain TBI
0-4 y/o 15-19 y/o 65+ 75+ have highest rates of TBI death Males Soldiers from Iraqi war
Majority of sports injuries occur due to
Football!
also hockey, soccer, rugby
What is damage in a concussion due to
axonal injury from coup-contra coup
head back/brain forward- head forward/brain back
What are symptoms of a concussion
Confusion (answers slowly) memory loss visual disturbance (diplopia, photophobia) Impaired balance headache
Post concussive syndrome is
when symptoms last >1 week with cognitive difficulties and a cluster of physical and sleep symptoms
How do you diagnose concussion
clinically- CT only if LOC or GCS <15, or serious injury
What is different about athletes and concussions
they need to be evaluated by experienced clinicians (SCAT5) with specific protocol to return to play
What is the Brain Trauma Indicator
new lab test that measures proteins (UCH-LI and GPAP) released from the brain into blood w/in 12 hours of injury (Predicts patients that will show intracranial lesions on CT)
What is Tx for concussion
physical and mental rest + APAP
gradually increase activity
What is an EDH
blood accumulates between the dura and bone (IC or spinal)
When is an EDH an emergency (fatal)
if intracranial !
What is the pathophys of an EDH
linear force to skull causes periosteal dura to separate from bone= vessel damage
usually skull Fx
Does expansion stop?
it is rapid, but stops at suture lines
What are symptoms of an EDH
delayed decline
ALC, HA, N/V, Sz, focal neuro deficits (aphasia, weakness, numbness)
Spinal EDH: weakness, change in DTR, sensory deficit with radicular paresthesias, bladder and bowel dysfunction
What will EDH PE show
increased ICP (bradycardia, HTN)
skull Fx
Hematoma
raccoon eyes (basilar skull Fx)
battle sign
CSF otorrhea and rhinorrhea, hemotympanum
Decerebrate, decorticate, altered GCS, weakness, Doll eye (oculocephalic reflex), anisocoria (ipsilat dilation), CN VII injury
Common brain herniations include
*Subfalcine (HA, contralateral leg weakness)
Tonsillar (obtunded)
Transtentorial (CN III ipsilat abn EOM and pupil/ contrala hemiparesis)
What are symptoms of a brain herniation
increased ICP causing Cushing’s triad
HTN, resp depression, bradycardia
EDH workup includes
CBC
Coags
Tox screen
type and screen (ab-ag for blood transfusion)
What will EDH CT show
midline shift- white aint right
LENS shaped
What is Tx for EDH
Emergent decompression (burrhole on side of DILATD pupil/injured side)
Elevate head 30-45
+/- coagulopathy (FFP, Vitamin K, protamine)
How can you treat an intubated EDH patient
Hyperventilate = hypocapnia = vasoconstriction = decrease ICP
*but, you increase ischemia
What meds can you use for an EDH
Diuretics (mannitol) or Hypertonic saline (for high ICP)
Tylenol to decrease fever
anticonvulsants for prophylaxis
What med can you give for a spinal EDH
high dose methylprednisone
What is the definitive Tx for EDH
Surgery; craniotomy or laminectomy to evacuate hematoma
What is a SDH
blood below inner dural layer, extending to brain and arachnoid
How can you categorize SDH
Acute <72 hours
Subacute 3-7 days
Chronic >7 days
Who often gets SDH
Elderly on anticoags
s/p LP
Spontaneous
What is the MOA of SDH
coup-contre coup: torn vessels (bridging veins) that connect surface of brain to dural sinus
Chronic SDH related to cerebral atrophy
What can an SDH lead to
Herniation
small SDH resolve spontaneously
How does Acute SDH present
mod-severe injury
comatose
presentation depends on location
How does chronic SDH appear
insidious in 40+ y/o (older brain= more atrophy)
decreased LOC, HA, gait abn/imbalance, memory loss, personality changes, motor deficits, aphasia, seizure
What does a SDH PE show
GCS <15 with blunt head trauma (GET A CT) HA confusion nausea speech difficulty diplopia weakness
What does a SDH workup include
emergent non-con CT (when patient is stabilized)
If GCS worsens by 2+ points, repeat imaging
labs (same as EDH; CBC, coags, tox screen, type and screen)
MRI or CT for SDH
MRI is better, but CT is faster and more available
What does an acute SDH show on CT
CRESCENT shaped mass (white aint right) (hyperdense)
-chronic SDH is darker (isodense) and harder to see on CT
How do you treat an acute SDH
ABC
osmotic diuretic
surgical decompression
What is the prognosis of Acute SDH
poor; due to likely brain injury
Why do Acute SDH patients need ICU post op
strict BP control (dont want it to be too high and have them bleed again)
ventilator respiration
What is Tx for chronic SDH
surgery not needed w/o mass effect or symptoms
