EM basics Flashcards
AMS Ddx “AEIOU TIPS”
Anemia Electrolytes, Epilepsy, Encephalopathy Insulin Opiates, Oxygen Uremia Trauma, Temperature Infection Poisons, Psychogenic Shock, Stroke, Sepsis, Subarachnoid hemorrhage, Space-occupying lesion
Causes of AMS that could be found on ABCDE’s?
Airway - hypoxemia
Breathing - Respiratory acidosis
Circulation - BP? Hypo perfusion
Disability - Spinal cord injury or Stroke
Environment - Hyperthermia, hypothermia, CO poisoning
Expose - Drug patches, dialysis ports, catheters, petechiae, trauma
Steps of management for all AMS patients?
Assessment of ABCs
Cardiac Monitoring and pulse oximetry
D-stick
O2 support if hypoxic
IV access
Assessment for signs of trauma and c-spine placement
Naloxone if narcotic etiology is suspected
Three categories of types of AMS?
Delirium
Dementia
Psychosis
Describe delerium
Normal consciousness requires both arousal and cognition. Arousal is mediated primarily by brainstem nuclei (reticular activating system) while cognition and organized thought is dependent on cortical functioning.
Delirium is brain dysfunction resulting in alterations of both level of arousal and thought content. Isolated structural lesions are incredibly unlikely to involve brainstem and bilateral cortical structures and still leave the patient alive. Delirium is almost always caused by an underlying medical problem that has toxic or metabolic affects on the brain. Screening for delirium in all altered patients is critical because it may lead us down our diagnostic pathway.
GCS: How is eye opening graded?
4 - Spontaneous opening
3 - Open to sound
2 - Open to pain
1 - Do not open
GCS: How is verbal communication scored?
5 - Oriented 4 - Confused 3 - Inappropriate words 2 - Incomprehensible sounds 1 - None
GCS: How is motor response scored?
6 - Obeys commands
5 - Localizes to pain
4 - Withdraws from pain
3 - Decorticate posturing (Flexion posturing)
2 - Decerebrate posturing (Extension posturing)
1 - No response
What are the procedures of the 3-hour sepsis bundle?
Lactate measurement
Blood cultures obtained before the administration of Abx
Administration of broad spectrum Abx
fluid support of 30mL/kg for patients lactate > 4mmol or hypotension (Careful with patients with major comorbidities)`
What are the procedures of the 6-hour sepsis bundle?
Admin of vasopressors for persistent hypotension after fluid resuscitation to achieve a MAP > 65
Reassess and document volume status in patients who remain hypotensive/lactate > 4 after fluid resuscitation
Repeat lactate tests for patients with initial lactate > 4
What are the criteria for identifying end organ dysfunction in sepsis?
SBP less than 90, greater than 40 point drop from baseline, or MAP under 70
Creatinine above 2 or urine output less than 0.5mL/kg/hr for 2+ hours
Bilirubin above 2
Platelets less than 100,000
INR above 1.5 or PTT greater than 60s
Lactate greater than 2 mmol
Definition of septic shock?
Persistent hypotension despite fluid resuscitation of 30mL/kg
First tests for suspected sepsis?
CBC with diff CMP PT/INR Blood culture x2 Urinalysis with culture and sensitivity
Optional depending on suspicion: Third blood culture: endocarditis CSF: meningitis Arthrocentesis: septic arthritis Wound cultures
Diagnostic criteria for sepsis?
clinician concern for infection combined with evidence of either hypoperfusion of end organs or hypotension.
Sepsis: timing of antibiotics?
A retrospective review of 17,990 patients in the Surviving Sepsis Campaign’s database showed little change in mortality between 0 and 5 hours time to antimicrobial administration.
