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WI18 Neuro > AMS/Delirium/Coma/etc, > Flashcards

AMS/Delirium/Coma/etc, Flashcards

1
Q

elements of mental status (7)

A
  1. Level of consciousness
  2. attention/concentration/memory
  3. speech and language
  4. visual spatial perceptions, executive function
  5. mood and affect
  6. thought content
  7. praxis
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2
Q

levels of consciousness

A

ALOC

alert and oriented
lethargic
obtunded
coma

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3
Q

praxis

A

performance of action in absence of primary deficits in motor and spatial ability

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4
Q

apraxia

A

inability to perform purposeful action

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5
Q

Altered mental status

A

alteration in consciousness characterized by:

disordered attention + diminished speed, clarity, coherence

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6
Q

AMS history

A

determine what is considered AMS for the individual patient

determine if problem is due to medical, psychiatric, neuro illness

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7
Q

what indicates neuro cause of AMS

A

memory problems

problems with thought = psychiatric

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8
Q

important signs on PE of AMS

A

abnormal vitals
depressed levels of consciousness
signs of toxidrome
focal neurological impairment

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9
Q

tools used to asses mental states (4)

A

Six Item Screener
CAMs
Glascow coma scale
brain death exam

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10
Q

six item screener

A

easier than MMSE in ED

broad, allows you to ID AMS

score below 5 indicates cognitive impairment

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11
Q

foremost concern when dealing with altered patient?

A

patient and staff safety!

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12
Q

steps in AMS management

A
  1. Quiet room and clam conversation
  2. Sedative (Lorazepam/Ativan)
  3. Chemical sedation (B-52 - Benadryl + Haldol + Ativan)
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13
Q

Delirium

A

special AMS characterized by increased vigilance with psychomotor and autonomic over activity

ACUTELY ILL **

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14
Q

epidemiology of delirium

A

30% of older medical pts during hospitalization

highest in elderly, cardiac surgery pts

more severe the illness, more likely to have presentation of delirium (ICU MC)

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15
Q

delirium pathology

A

multifactoral

disruption of reticular activating system

cytokine inflammation (I.e. sepsis) provokes microglia

Acetylcholine disregulation (I.e. 2/2 anticholinergic drugs) `

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16
Q

challenges in delirium history

A

first challenge: avoid bias

next: determine baseline

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17
Q

test done used to identify delirium

A

CAMS

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18
Q

CAM algorithm

A
  1. acute onset and fluctuating course
  2. inattention/distractibility
  3. disorganized thinking, illogical, unclear ideas
  4. alteration in consciousness

must have 1 and 2, either 3 or 4

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19
Q

delirium clinical presentation

A

ACUTE onset (over hours to days, persists for days to months)

disorientation, auditory/visual hallucinations

common in elderly and may be only finding of a more severe illness

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20
Q

etiologies of delirium (8)

A

MEDICATION LIST *****

alcohol withdrawal

CNS infection

sepsis due to systemic infection

electrolyte derangement

encephalopathy

CNS conditions

Systemic organ failure

hepatic encephalopahty

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21
Q

medications causing delirium

A
  1. sedating medications
  2. over the counters
  3. drug withdrawal/alcohol withdrawal
  4. poisons
  5. polypharmacy
  6. side effects from medications
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22
Q

delirium tremens

A

most severe form of alcohol withdrawal

severe hallucinations, disorientation, tachycardia, HTN, fever, agitation, diaphoresis

can persist for 1 week, be fatal (cardio)

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23
Q

delirium tremens diagnosis

A 
clinical features (hx of alcoholism
withdrawal symptoms
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24
Q

delirium tremens prevention

A

Benzo bolus if suspected or history of withdrawal seizures

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25
management of delirium tremens
supportive care benzos IV/PO severe: phenobarbital/propofol/dexmedetomidine
26
CNS infections and delirium
meningitis and encephalitis can cause if unsure source of delirium, consider a LP
27
systemic infection delirium
UTI, PNA, cellulitis, intra abdominal infection
28
wernicke's encephalopathy
uncommon cause of delirium due to thiamine (B1) deficiency typically in alcoholics, hemodialysis pts
29
clinical triad of wernicke's encephalopathy
encephalopathy (delirium) oculomotor dysfunctoin gait ataxia
30
Korsakoff syndrome
untreated wernicke's encephalopathy form of dementia/psychosis, memory loss, lack of insight, apathy, and confabulate can cause coma, death
31
tx of korsakoff/wernicke's
500 mg thiamine IV daily thiamine
32
glucose and thiamine
administration of glucose can cause the encephalopathy bc glucose causes thiamine reserves to be used up
33
Hepatic encephalopathy
caused by cirrhosis, due to impaired clearance of ammonia and other toxins
34
clinical présentation of Hepatic encephalopathy
cognitive defects with impaired neuromuscular function bradykinesia, asterixis
35
Hepatic encephalopathy management
supportive, restrict protein intake lower ammonia levels via: lactulose, rifaximin
36
hypercarbia induced delirium
found in pts with COPD given too much oxygen, slowing down drive the breathe therefore causing levels of CO2 to increase check ABG in pts with delirium
37
mimics of delirium
dementia (insidious, chronic) non convulsive epilepsy primary psychiatric disorders (depression, mania)
38
diagnostic tests for delirium
common labs (chem panel + tox) EKG, CXR CT Scan LP ( + CT)
39
tx of delirium
treatment of underlying condition close monitoring pharm is risky bc can worsen delirium (haldol for agitation)
40
when are physical restraints used in delirium
immediate threat to themselves or others only for a short period of time
41
coma
un-arousable, unaware of surroundings unresponsive to external stimulation within 2 weeks, will either go to one of two categories
42
two categories of coma pts
persistent vegetative state | brain death
43
persistent vegetative state
wakefulness without awareness or surroundings no movements, no interaction with others
44
brain death
irreversible cessation of cerebral brainstem function
45
acute coma
acute alteration in arousal life threatening, prompt intervention required
46
historical information for coma pts
DRUG USE history (illegal, prescription) recent illness focal neuro losses recent trauma?
47
general exam of pt with coma
``` vital signs + ABCs skin pupillary response, eye movements reflexes Glasgow coma scale ```
48
which way do the eyes go in caloric testing?
movement towards stimulus coma neuro exam
49
coma postures
decorticate decerebrate flaccid
50
pts in persistent vegetative state are which coma posture
flaccid
51
decorticate posture
damage to cerebral hemispheres, internal capsule and thalamus NOT brain death
52
decerebrate
damage to brain stem NOT brain death progression from decorticate indicates herniation
53
brain death
hypoxic-ischemic brain injury via cardiopulmonary arrest, vascular catastrophe, poisoning, head trauma absence of cerebral and brainstem function
54
req. to diagnose brain death
1. imaging of acute CNS catastrophe 2. exclusion of other conditions that may have confounded assessment 3. no drug intoxication 4. core temp >97 5. SBP > 100
55
brain death exam
imaging neurologic exam to determine absence of function apnea test
56
response that indicated brain stem dysfunction? Brain death? oculocephalic and caloric response
asymmetric = brain stem non response = coma
57
apnea test
done in brain death patients to determine if spontaneous respirations occur can't be don for those with spinal cord injury, nmj paralysis, high CO2 retainer history
58
spinal reflexes and brain death
some reflexes come from the spine therefore present despite brain death facial nerve movement, finger movements, Lazarus (neck displacements)
59
liver mortis
lividity that occurs to the corpse after death due to pooling of blood from gravity 20 min - 3 hrs after death
60
causes of dizziness
``` peripheral vertigo (in ear) central vertigo pre-syncope disequilibrium nonspecific dizziness ```
61
key historical aspect of vertigo | indicators of peripheral vertigo
exacerbate via head movement transient nystagmus Dix Hallpike maneuver provokes it
62
indicators of Meniere's Dz
peripheral vertigo hearing loss or tinnitus
63
tx of vertigo
medications that suppress vestibular system antihistamines, phenothiazine, benzos
64
suggestions of central vertigo
ataxic gait, HA, doubled or loss of vision, slurred speech, numbness, weakness, clumsiness, incoordination non contrast CT

WI18 Neuro (16 decks)

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