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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
Q

management of delirium tremens

A

supportive care
benzos IV/PO

severe: phenobarbital/propofol/dexmedetomidine

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26
Q

CNS infections and delirium

A

meningitis and encephalitis can cause

if unsure source of delirium, consider a LP

27
Q

systemic infection delirium

A

UTI, PNA, cellulitis, intra abdominal infection

28
Q

wernicke’s encephalopathy

A

uncommon cause of delirium

due to thiamine (B1) deficiency

typically in alcoholics, hemodialysis pts

29
Q

clinical triad of wernicke’s encephalopathy

A

encephalopathy (delirium)
oculomotor dysfunctoin
gait ataxia

30
Q

Korsakoff syndrome

A

untreated wernicke’s encephalopathy

form of dementia/psychosis, memory loss, lack of insight, apathy, and confabulate

can cause coma, death

31
Q

tx of korsakoff/wernicke’s

A

500 mg thiamine IV

daily thiamine

32
Q

glucose and thiamine

A

administration of glucose can cause the encephalopathy bc glucose causes thiamine reserves to be used up

33
Q

Hepatic encephalopathy

A

caused by cirrhosis, due to impaired clearance of ammonia and other toxins

34
Q

clinical présentation of Hepatic encephalopathy

A

cognitive defects with impaired neuromuscular function

bradykinesia, asterixis

35
Q

Hepatic encephalopathy management

A

supportive, restrict protein intake

lower ammonia levels via: lactulose, rifaximin

36
Q

hypercarbia induced delirium

A

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
Q

mimics of delirium

A

dementia (insidious, chronic)

non convulsive epilepsy

primary psychiatric disorders (depression, mania)

38
Q

diagnostic tests for delirium

A

common labs (chem panel + tox)
EKG, CXR
CT Scan
LP ( + CT)

39
Q

tx of delirium

A

treatment of underlying condition

close monitoring

pharm is risky bc can worsen delirium (haldol for agitation)

40
Q

when are physical restraints used in delirium

A

immediate threat to themselves or others

only for a short period of time

41
Q

coma

A

un-arousable, unaware of surroundings

unresponsive to external stimulation

within 2 weeks, will either go to one of two categories

42
Q

two categories of coma pts

A

persistent vegetative state

brain death

43
Q

persistent vegetative state

A

wakefulness without awareness or surroundings

no movements, no interaction with others

44
Q

brain death

A

irreversible cessation of cerebral brainstem function

45
Q

acute coma

A

acute alteration in arousal

life threatening, prompt intervention required

46
Q

historical information for coma pts

A

DRUG USE history (illegal, prescription)

recent illness

focal neuro losses

recent trauma?

47
Q

general exam of pt with coma

A 
vital signs + ABCs 
skin 
pupillary response, eye movements 
reflexes 
Glasgow coma scale
48
Q

which way do the eyes go in caloric testing?

A

movement towards stimulus

coma neuro exam

49
Q

coma postures

A

decorticate
decerebrate
flaccid

50
Q

pts in persistent vegetative state are which coma posture

A

flaccid

51
Q

decorticate posture

A

damage to cerebral hemispheres, internal capsule and thalamus

NOT brain death

52
Q

decerebrate

A

damage to brain stem

NOT brain death

progression from decorticate indicates herniation

53
Q

brain death

A

hypoxic-ischemic brain injury

via cardiopulmonary arrest, vascular catastrophe, poisoning, head trauma

absence of cerebral and brainstem function

54
Q

req. to diagnose brain death

A
  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
Q

brain death exam

A

imaging

neurologic exam to determine absence of function

apnea test

56
Q

response that indicated brain stem dysfunction? Brain death?

oculocephalic and caloric response

A

asymmetric = brain stem

non response = coma

57
Q

apnea test

A

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
Q

spinal reflexes and brain death

A

some reflexes come from the spine therefore present despite brain death

facial nerve movement, finger movements, Lazarus (neck displacements)

59
Q

liver mortis

A

lividity that occurs to the corpse after death due to pooling of blood from gravity

20 min - 3 hrs after death

60
Q

causes of dizziness

A 
peripheral vertigo (in ear) 
central vertigo 
pre-syncope 
disequilibrium 
nonspecific dizziness
61
Q

key historical aspect of vertigo

indicators of peripheral vertigo

A

exacerbate via head movement
transient nystagmus
Dix Hallpike maneuver provokes it

62
Q

indicators of Meniere’s Dz

A

peripheral vertigo

hearing loss or tinnitus

63
Q

tx of vertigo

A

medications that suppress vestibular system

antihistamines, phenothiazine, benzos

64
Q

suggestions of central vertigo

A

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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