AMS & Toxicology Flashcards
Not fully alert
drifts to sleep
limited awareness
loses train of thought
Lethargic/somnolent
difficult to aroused
confused when aroused
stimulation required to elicit minimal cooperation
obtunded
doesn’t rouse spontaneously
vigorous stimulation for very little response
moan or mumble when aroused
stuporous/semicomatose
unarousable unresponsiveness…
coma
minimum GCS even if dead…
3
GCS scoring…
Eye: 1-4
Motor: 1-6
Verbal: 1-5
What posturing?
flexion w. adduction of arms and extension of legs
(flexor posturing)
decorticate
COR - hands over heart
This type of posturing a/w corticospinal lesion (cortex to upper midbrain)
decorticate
What posturing?
extension, adduction, internal rotaion of arms and leg extension
(extensor posturing)
Decerebrate
Decerebrate posturing is associated with damage where?
brainstem (pons, upper medulla)
Which is worse, decorticate or decerebrate?
decerebrate
Dementia (or Major Neurocognitive Disorder) has significant cognitive impairment in 1 of 6 domaines…
learning/memory
language
executive function
complex attention
perceptual motor function
social cognition
A fluctuating disturbance in attention and awareness and cognition developing over a short period of time…
delerium
are focal or lateralized neuro findings characteristic of delerium?
no
MOVE STUPID describes what etiology of AMS
metabolic
oxygen
vascular
endocrine
seizure trauma uremia psych infx drugs
initial lab workup for AMS
lytes Cr Glucose Ca CBC UA Urine Preg
What diagnostic for AMS?
CAD hx or age > 50
ECG
What diagnostic for AMS?
resp sxs
fever
CXR
What diagnostic for AMS?
focal neuro exams
hx of trauma
Head CT
What diagnostic for AMS?
hypoxic
suspected metabolic acidosis
ABGs
3 tx options that pose little harm in tx of AMS
thaimine
dextrose
naloxone
Physical restraints should be used when with AMS?
last resort
What 3 things can lessen disruptive behavior in AMS?
frequent reassurance, touch, verbal orientation
Haloperidol should be reserved for…
potential harm to patient, providers, family
BZs as a tx for undifferentiated AMS?
no
are cholinesterase inhibitors effective in tx of delerium?
no
When can BZs be considered for AMS?
withdrawal
sympathomimetic/anticholinergic poisoning
delirium may take _____ to resolve
weeks to months
4 important questions for toxicology hx?
which toxin?
how much?
when?
precipitating event?
Cholinergic like organophosphates cause physiologic ______
depression
The below are examples of what kind of decon?
- Forced diuresis
- Urine ion trapping
- Hemodialysis
- Exchange transfusion
enhanced elimination
Amitriptyline antidote
sodium bicarb
anticholinergic antidote
physostigmine
beta blocker antidote
glucagon
cyanide antidote
hydroxocobalamin/nitrates
hydrofluoric acid antidote
calcium
iron antidote
desferrioxamine
methanol/ethylene glycol antidote
ethanol
methemoglobin antidote
methyline blue
organophosphates/anticholinesterase antidote
atropine, 2-PAM
salicylate antidote
urine alkalization, dialysis
sulfonylurea antidote
octreotide
Urine or serum tests?
- Opioids
- Benzos
- Cocaine
- THC
- Barbiturates
- Amphetamines/methamphetamines
- TCAs
- Buprenorphine
urine
urine or serum tests?
- Acetaminophen
- Salicylate
- Carboxyhemoglobin
- Digoxin
- Lithium
- Iron, lead, mercury
- Ethylene glycol
- Antiepileptic drugs
Serum
4 labs for all poisonings and patients w. AMS
preg
glucose
acetaminophen/salicylate testing
Cholinergic toxidrome sxs:
SLUDGE and Killer BBBs
Salivation Lacrimation Urination Defecation GI distress Emesis
Bradycardia, Bronchorrhea. Bronchospasm
Cholinergic toxidrome tx…
agressive decon
atropine + 2 PAM
Anticholinergic toxidrome drugs (2)
antihistamines
jimson weed
Earliest and most reliable sign of anticholinergic toxidrome…
tachycardia
Tx of anticholinergic poisoning…
BZs for agitation
Activated charcoal if recent
Physostigmine
What toxidrome?
- Hyperthermia
- Tachycardia/dysrhythmia
- HTN
- Diaphoresis
- Agitation, hallucinations, paranoia
- Dilated pupils
- Seizures (
sympathomimetic
How can you tell sympathomimetic vs anticholinergic?
anticholinergic = dry skin, hypoactive BS
Sympathomimetic = diaphoresis, hyperactive BS
Which toxidrome?
- Hypothermia
- Vitals usually relatively normal
- Bradypnea/apnea
- CNS depression, coma
- Hyporeflexia
- VARIABLE pupils
sedative hypnotic
Tx for sedative hypnotics…
time +/- flumazenil