Confusion Flashcards
What syndromes can make a patient appear confused
Dementia Delirium Psychosis Expressive dysphasia Receptive dysphasia
What questions can you asked someone who presents as confused
Are the oriented to time, place, and person?
Can they tell you why they are here? (AMTS)
Can they follow a 3 step command? Can they name 3 common objects?
Are they in pain? Is there breathlessness, cough, or urinary symptoms
What questions can you ask to a confused patient’s accompaniment
What their normal state is
If the confusion is sudden or gradually worsening
Drug history (includes alcohol)
What are the categories in the INVITED MD mnemonic surgical sieve and give some examples of each in the context of confusion causes
Infectious (chest, UTI, encephalitis, brain abscess, sepsis)
Neoplastic (brain tumour)
Vascular (stroke, MI -> hypoperfusion)
Immune (neuropsychiatric lupus, Hashimoto’s encephalopathy)
Trauma (subdural haematoma, extradural)
Endocrine (hypothyroidism, hyperthyroidism, diabetic ketoacidosis)
Drugs (alcohol, opiates, psychiatric medications, diuretics, digoxin, thyroid medication
Metabolic (hypoxia, hypercapnia, hypoglycaemia, hypercalcaemia, electrolyte imbalance, thiamine/B12/folate deficiency)
Degenerative conditions
What vital signs are important in investigating confusion
Blood pressure Pulse and resp rate Oxygen saturation Temperature Blood glucose
Why may BP be useful in investigating confusion
Hypoperfusion of the brain decreases consciousness
hypertension + bradycardia -> Cushing response to intracranial pressure
Why may pulse and resp rate be useful in investigating confusion
Tachycardia or tachypnoea can be secondary to infection
Why may oxygen saturation be useful in investigating confusion
hypoxia will affect consciousness
Why may temperature be useful in investigating confusion
Fever -> infection
Hypothermia can cause confusion
Why may Blood glucose be useful in investigating confusion
Hypoglycaemia or hyeprglycaemia can depress consciousness
What investigations would you do on patients who are difficult to examine (due to confusion)
Consciousness using GCS Septic focus Pupils Focal neurological signs Needle track marks Asterixis Breath Bitten tongue
What do you focus on in assessing septic focus
Chest
Urine
Cellulitis
Meningitis
What signs would you look for in a chest infection
Dull percussion
Bronchial breathing and crackles
What signs would you look for in a urine infection
Suprapubic tenderness
Cloudy urine (in catheter bag)
Urinalysis + send specimen for MC&S
What signs would you look for in cellulitis
Look at the skin
Pay attention to the feet in diabetics
Check venous or arterial lines
What signs would you look for in meningitis
Neck stiffness -> meningism
Photophobia
Purpuric rash (meningococcal septicaemia)
What are the 3 components of GCS
Eyes
Motor
Verbal
What are you assessing in the eyes for confusion
Pupil symmetri, size, and direct consensual response to light
What causes pupils to become pinpoint
Drug overdose (tricyclic anti-depressants, cocaine)
Severe hypoxia
Hypothermia
Postictal
What causes pupils to become dilated
Opiate or barbiturate overdose
What causes asymmetrical pupils
anisocoria, can be normal
Suggestive of coning secondary to raised intracranial pressure or 3rd nerve palsy
What focal neurological signs do you look for in confusion
Dysphasia, visual field defects, nystagmus, tone, reflex symmetry, plantar responses, focal weakness, ataxia and sensory or visual inattention
Suggests stroke or SOL
What does asterixis suggest
Hypercapnia
Hepatic encephalopathy
Uraemia
What do you look for in the breath on investigation
Alcohol Fetor hepaticus (liver failure) Uraemic fetor (renal failure) Fruity breath (ketones in ketoacidosis)
What does a bitten tongue suggest
convulsive seizure
What does a confusion screen consist of
Septic screen
Metabolic screen
Toxicology screen
ECG
What are the positive signs of infection in urine analysis
MSU - +ve leucocyte esterase and nitrites
What does glucose and ketones in the urine suggest
Diabetic ketoacidosis
Which electrolyte imbalances cause confusion
Low sodium
High calcium
What is in a septic screen for confusion
FBC CRP Blood cultures Urine analysis Urine MC&S CXR
What is in the metabolic screen for confusion
Blood gas U&Es TFTs Liver enzymes Thiamine Folate B12
What in LFTs may suggest alcohol abuse
Raised gamma-glutamyl transferase (GGT)
What is the management for confusion
Ensure patient is not left unattended Put them in a quiet side room if possible Discontinue non-essential medications Promote good sleep hygiene Fluids and nutrition
If you are unable calm a confused patient, what are your next steps
Haloperidol - 30-60 minutes (can have extra-pyramidal effects)
Lorazepam - 5-10 minutes
What does high or normal osmolality with hyponatraemia suggest
Pseudohyponatraemia
Low sodium due to artefact
High - hyperglycaemia, mannitol, glycine
Normal - hyperlipid, hyperprotein
What are the causes of hyponatraemia if the patient is hypervolaemic
Congestive cardiac failure
Hepatic failure
Nephrotic syndrome
What are the causes of hyponatraemia if the patient is euvolaemic
High urine osmolality - SIADH
Normal urine - fluid overload, hypothyroidism
What are the causes of hyponatraemia if the patient is hypovolaemic
Na loss is renal - Diuretics, renal failure, addisons, pyelonephritis
Na loss is not renal - vomiting, diarrhoea, cutaneous loss through sweating and burns, pancreatitis, small bowel obstruction
What is the treatment for hypoglycaemia
Conscious - sweet drink or glucose tablets
Unconscious - Dextrose gel, 50 mL 20% glucose / 250ml 10% glucose IV, IM glucagon
What are the clinical signs of DKA
Polyuria, polydipsia and reduced mental state (hyperglycaemia)
Nausea, vomiting, abdo pain, fatigue, SOB, Kussmaul breathing
Hypotension and tachy (dehydration)
Ketotic breath
How does opiate overdose compare to cocaine overdose
opiates - pinpoint pupils and respiratory depression
Cocaine - dilated pupils, sinus tachy, hypotension and pyrexia. May have resp. distress and urinary retention
How do tricyclics overdose present
Sympathetic - pupil dilation, tachy, brisk reflex, urinary retention
Para - dry mouth and drowsiness
What treatment should be given for confusion with Hx of alcohol abuse and why
Thiamine e.g. pabrinex
Prevent Wernicke’s encephalopathy -> Korsakoff’s syndrome (amnesia and confabulation)
What are the indications for immediate CT scan
GCS <13 on arrival GCS <15 2h post incident Post traumatic seizure Focal neurological deficit Vomiting > 1 Suspected skull fracture
What are the criteria for urgent (8h) CT head
Any head injury on warfarin
Loss of consciousness or amnesia + >65, fall > 1m or > 5 stairs, pedestrian/bicycle vs vehicle, more than 30mins amnesia before injury
