AMS Flashcards
What is the first step when encounter pt suspected to have AMS?
Prove it!
- 1st option: Get in their ears and YELL “Open your eyes”. Often that is all it takes to wake them up
- Second: noxious stimuli
• Sternal rub (try to keep family from seeing)
• Stimulate nail beds on bilateral hands and feet
• Posturing?
• Purposeful movement?
Glasgow coma scale
- three sections and number of points each
- eyes (4 points)
- verbal (talks 5 points)
- motor (motors 6 points)
Glasgow coma scale
- eyes points
- 4: spontaneous
- 3: verbal stimuli
- 2: to pain
- 1: none
Glasgow coma scale
- verbal points
- 5: oriented
- 4: confused
- 3: inappropriate words
- 2: incoherent
- 1: none
Glasgow coma scale
- motor points
- 6: obeys commands
- 5: localizes pain
- 4: withdraws from pain
- 3: flexion to pain/decorticate
- 2: extension to pain/decerebrate
- 1: none
ABCDE define
- airway
- breathing
- circulation
- disability/dysfunctional CNS
- exposure
Mnemonic for trauma
Oh My My, I’ve Lost the Vital Signs
- oxygen
- monitor (hook up)
- IV: two large bore
- Labs
- Tubes: NG, foley, etc.
- Vital signs
Mnemonic for medical
Don’t Forget
- dextrose: give sugar or check fsbs
- O2: if hypoxic
- Narcan: opiate OD
- Thiamine: Wernickes or Korsakoff
- Flumazenil: benzo antidote
- Dont’ forget to do a PE!!
What to be a careful about when administering Flumazenil
If pt took TCAs and benzo, the benzo will treat the seizures the TCA OD will cause, if block the effect of the benzo via the antidote, pt might start seizing…
Mnemonic: things to order when patient is comatose
ABCDEFP
Mnemonic: things to order when patient is comatose
- A
- AGB: acidosis vs. alkalosis. Pulse ox works for this too… VBG also an option
- Ammonia: alcoholism leads to injury leads to high ammonia. Act funny or comatose
Mnemonic: things to order when patient is comatose
- B
blood alcohol, are they just drunk?
Mnemonic: things to order when patient is comatose
- C
- CBC: anemia, infection, shift, sepsis evidence, etc.
- CMP: hyponatremia, other electrolyte abnl
- CO: poisoning
- CULTs: urine and/or blood. Will help if they get admitted
- CXR: usually a good idea :) pneumonia, pneumothorax
- CT: very expensive, should not be a first line test, wait until others come back and then consider if nothing else is helping…
Mnemonic: things to order when patient is comatose
- D
- Drug screen: (urine or blood), Tylenol level, ASA level
- Drug levels: If you know what the patient is on, for example dilantin, phenobarbitol, etc.
Mnemonic: things to order when patient is comatose
- E
EKG: TCA OD typically presents with tachycardia and widened QRS, bat-wing t-wave with SAH, other dysrhythmias!
Mnemonic: things to order when patient is comatose
- F
Female: pregnancy test
Mnemonic: things to order when patient is comatose
- P
- Pee: UA
- pb (lead): lead level
Anion gap calculation
Na - (bicarb + Cl)
normal is about 12
Mnemonic for ddx for increased anion gap acidosis
MUD PILE CATS
Mnemonic for increased anion gap acidosis
- M: ddx and how to test
- Methanol: methanol level, takes a long time to get results
- Metformin: lactic acid level
Mnemonic for increased anion gap acidosis
- M: tx
- Methanol itself is not toxic but alcohol dehydrogenase breaks it down into formic acid, which is toxic. First aim is to prevent breakdown of methanol. Tie up all their alcohol dehydrogenase by giving them alcohol to a blood alcohol level of 150. Can buy booze or an alcohol drip. Can also use fomepizole but it is very expensive
- To get rid of methanol: hemodialysis. Dialysis will also take off the alcohol so have to increase the drip (get them more drunk)
Mnemonic for increased anion gap acidosis
- U: ddx and how to test
Uremia: BUN, Cr
Mnemonic for increased anion gap acidosis
- U: tx
Admit to hospital and let internist take care of it
Mnemonic for increased anion gap acidosis
- D: ddx and how to test
DKA: ketones, blood sugar
Mnemonic for increased anion gap acidosis
- D: tx
Admit to hospital and let internist take care of it
**If have to pick ONE treatment, pick fluids (not insulin or K)
Mnemonic for increased anion gap acidosis
- P: ddx
- Paraldahyde
- Phenformin
Mnemonic for increased anion gap acidosis
- I: ddx and how to treat
- INH (isoniazid): CXR to look for TB
- Iron: iron level and TIBC (total iron binding capacity). If Iron > TIBC, then have iron OD
Mnemonic for increased anion gap acidosis
- I: tx
- INH: bicarb
Mnemonic for increased anion gap acidosis
- L: ddx and how to test
Lactic acidosis: caused by lots of things (sepsis, bowel infarct, etc.) if get positive result, more tests to run to find cause
Mnemonic for increased anion gap acidosis
- E: ddx and how to test
Ethylene glycol
- Fluorescein urine (glows)
- Serum osmolality (see below)
- Calculated (not as good)
- Measured (using freeing point depression method)
- Gaps between measured and calculated are caused by methanol and ethylene glycol
Mnemonic for increased anion gap acidosis
- E: tx
- Very similar to methanol treatment.
- Byproduct is hypuric acid not formic acid
Mnemonic for increased anion gap acidosis
- C: ddx and how to test
- Cyanide: breath smells like bitter almonds, only 1/3 people can smell it
- Cocaine: drug screen
Mnemonic for increased anion gap acidosis
- C: tx
- Cyanide: try try leave it up to fate (Amyl nitrate, sodium nitrate, sodium thiosulfate)
- Cocaine: bicarb
Mnemonic for increased anion gap acidosis
- A: ddx and how to test
- Alcoholic ketoacidosis (dt malnourishment, not alcohol)
- ASA: ASA level
Mnemonic for increased anion gap acidosis
- A: tx
- Etoh ketoacidosis: Admit to hospital and let internist take care of it
- ASA: bicarb
Mnemonic for increased anion gap acidosis
- T: ddx and how to test
Toluene (paint and whiteout), will see paint on face, metallic colors worst
Mnemonic for increased anion gap acidosis
- S: ddx, test, tx
- Starvation ketosis: usually dx on hx: fasting a long time
- Tx: feed them
What three compounds determine plasma osmolality?
- Na
- glucose
- BUN
How to calculate osmolar gap
= calculated osmolality - measured osmolality
what does an osmolar gap suggest?
- presence of extra solutes including methanol and ethylene glycol
What is the magic of 140?
Tylenol level
- if over 140 (4 hours later) they are toxic
- if calculate what they took and it was 140 mg/kg they are toxic
- tx is 140 mg/kg n-acetylcysteine
Mnemonic for ODs Bicarb can treat
SPLIT C
- Salicylates
- Phenobarbs
- Lithium
- INH (isoniazid)
- TCA ** KNOW THIS
- Cocaine
