EMED Block 2 Flashcards

1
Q

GCS for comatose, need for intubation and normal?

Define AMS

A

3- comatose
8 or less- intubate
15- normal

Umbrella term for delirium, dementia and coma or any change in mental status

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2
Q

Elderly PT w/ AMS is usually due to one of what 4 things?

What are the 5 contents of consciousness

A

Pneumonia/sepsis
UTI
Skin infection
Stroke

Reasoning
Language
Emotions
Self-awareness
Spatial relationship integration
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3
Q

Define Delirium

Define Dementia

Define Coma

A

D/o of consciousness affecting arousal, wakefulness or basic alerting- flickering light, who’s home?

Failure of content portion of consciousness w/ preserved alertness- lights on, nobody home

Failure of both arousal and content functions- lights off, nobody home

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4
Q

AMS Slide 8

A

Table

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5
Q

Define Mental Status

How is this usually tested?

A

Clinical state of emotional/intellectual function

Informal- person place time/season, current event

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6
Q

? is a transient d/o w/ impaired attention/cognition*

How will PTs present

A

Delirium

Difficulty focusing, shifting or sustaining attention
Confusion may fluctuate

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7
Q

How long does it take for delirium to develop?

What are the clinical features of this?

A

Hrs to days

Inc daytime somnolence
Agitation/sun-downing
HTN Asterixis Tremor Sweating

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8
Q

If delirium PT has hallucinations they are usually ? type

How is delirium D

A

Visual

Hx and PE
Primarily- Hx from caregiver, family, spouse

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9
Q

How can you tell the difference between depression and delirium?

What two Dxs have to be r/o when working up suspected delirium case

A
Delirium= rapid fluctuation
Depression= absent fluctuation, oriented, able to perform commands

Non-convulsive status epilepticus
Complex partial status epilepticus

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10
Q

What are 5 classes of issues that can induce acquired delirium

How are PTs w/ delirium Tx

What step is taken if a certain Tx step is done?

A
Metabolic/thyroid
Drugs
Infection
Neurologic
Cariopulmonary

Haloperidol 5-10mg PO/IV/IM
Benzos 0.5-2mg PO/IV/IM

Co2 Capnography

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11
Q

When would delirium PTs NOT be admitted

What are the two largest categories of dementia

A

Hypoglycemic
Uroseptic
Readily reversible agents

Idiopathic- Alzheimers
Vascular- multiple infarcts

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12
Q

How does dementia onset?

How do PTs w/ dementia present

A

Slowly w/ insidious Sxs

Hallucinations
Repetitive behaviors
Delusion/Depression

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13
Q

What is the characteristic onset of dementia associated w/ Alzheimers?

What are the 3 stages of dementia?

A

Impaired memory/orientation w/ preservation of motor/speech disability

Early: memory loss of names/items
Mid: early + reading, dec social function, loss of direction
Late: extreme disorientation, no self care, personality changes

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14
Q

What are the PE findings of vascular dementia?

How would a PT w/ dementia and Parkinson’s present?

A

Exaggerated/asymmetric DTRs
Gait abnormalities
Extremity weakness

Inc motor tone
Rigidity/movement d/o

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15
Q

What labs are ordered to assess dementia?

Vascular dementia requires ? for Dx

A

CBC CMP Syphilis TFTs UA B12
CXR HIV ESR Folate

Signs of cerebrovascular Dz on CT

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16
Q

What is the relation between a stroke and cognitive decline of dementia

Trifecta of ? issues can present as a mild dementia but functioning PT

A

Dementia w/in 3mon of stroke or,
Abrupt deterioration in memory/cognitive abilities

CHF UTI Hypothyroid

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17
Q

Define Pseudo-Dementia

How is dementia Tx

A

Depression imitating dementia

Anti-psychotics for persistent psychotic features due to s/e

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18
Q

How is vascular dementia Tx

When is a Dx of Normal Pressure Hydrocephalus considered in dementia PTs

A

Dec HTN/cholesterol

Large ventricles on head
Early development of urinary incontinence/gait disturbances (wet and wobbly)

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19
Q

Glasgow Coma Scale, Motor

A
6 Follow
5 Localize
4 Withdraws
3 Flex
2 Extend
1 None
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20
Q

Glasgow Coma Scale, Verbal

A
5 Orientated
4 Confused
3 Inappropriate
2 Incomprehensible
1 None
If PT is intubated, 'T' added in place
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21
Q

Glasgow Coma Scale, Eye Open

A

4 Spontaneous
3 To command
2 To pain
1 None

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22
Q

What labs are ordered to assess dementia?

Vascular dementia requires ? for Dx

A

CBC CMP Syphilis TFTs UA B12
CXR HIV ESR Folate

Signs of cerebrovascular Dz on CT

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23
Q

What is the relation between a stroke and cognitive decline of dementia

Trifecta of ? issues can present as a mild dementia but functioning PT

A

Dementia w/in 3mon of stroke or,
Abrupt deterioration in memory/cognitive abilities

CHF UTI Hypothyroid

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24
Q

Define Pseudo-Dementia

How is dementia Tx

A

Depression imitating dementia

Anti-psychotics for persistent psychotic features due to s/e

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25
# Define Uncal herniation How does this present on PE
Medial temporal lobe shifts, compresses brain stem= progressive drowsiness to unresponsive Sluggish ipsilateral pupil that dilates and is non-reactive as CN3 is compressed Ipsilateral hemiparesis
26
Glasgow Coma Scale, Verbal
``` 5 Orientated 4 Confused 3 Inappropriate 2 Incomprehensible 1 None ```
27
How does Central Herniation syndrome present Brain midline shifts w/out herniation correlates w/ ? What may be the underlying cause?
Decorticate posturing Irregular respiration Dec LoC Cerebral edema causing vascular compression Inc ICP
28
What is the max GCS score for an intubated PT What is the lowest score?
10T 3T
29
What GCS score correlates w/ a mild head injury? What GCS score correlates w/ a moderate head injury? What GCS score correlates w/ a severe head injury?
13-15 9-12 8 or less, reqs RSI
30
# Define Monro-Kellie doctrine What PE findings are used to assign causes of comas into categories?
Sum of brain, CSF and intracerebral blood volumes, inc of one causes dec of other one/two forces Breathing/eye movement/pupil findings Diffuse CNS dysfunction- toxic/metabolic coma Focal CNS- structural coma
31
Clinical features of Toxic-Mtabolic coma
No focal PE findings Small reactive pupils No EOMs= no value to differentiate toxic-metabolic from structural coma Except- barbituate poisoning= large pupils, no EOMs, flaccid muscles and apneic PT
32
Clinical features of Supratentorial Lesion coma
Progressive hemiparesis/asymmetric muscle tone or reflexes Hemipareisis is supsected if asymmetric responses to stimuli or asymmetric extensor/flexor posture ie- Uncal herniation
33
How are central herniations looked for on imaging? Cerebral blood flow is at ? MAPs
CT w/out contrast 50-100
34
What is the equation to find CPP What happens in the brain during uncontrolled ICP increase?
CPP= MAP - ICP Cerebral perfusion pressure dec as ICP nears MAP, leads to brain ischemia
35
What is a unique form of infratentorial induced coma? What are two methods to differentiate if a PT is faking a pseudocoma?
Pontine hemorrhage- pin point pupils Locked in Syndrome PT avoids gaze Nystagmus w/ caloric vestibular testing
36
Clinical features of Toxic-Mtabolic coma
No focal PE findings Small reactive pupils No EOMs= no value to differentiate toxic-metabolic from structural coma Except- barbituate poisoning= large pupils, no EOMs, flaccid muscles and apneic PT
37
How does a toxidrome present in comatose PTs How does opiate syndrome present? How does cholinergic syndrome present
Red skin EKG pupils sweating Hypovent, Small pupils Miosis Lacrimation Seizure
38
What marks the point in brain to differentiate above/below
Tentorium
39
What is the neuro imaging modality of choice for coma PTs When is a PT considered for non-convulsive status epilepticus
Non-contrast head CT Motor activity of seizure stops but PT doesn't wake <30min
40
What is a unique form of infratentorial induced coma? What are two methods to differentiate if a PT is faking a pseudocoma?
Pontine hemorrhage- pin point pupils Locked in Syndrome PT avoids gaze Nystagmus w/ caloric vestibular testing
41
What are the DDxs of Coma
``` AEIOUTIPS Alcohol Acidosis Ammonia Arrhythmia Endocrine E+ Encephalopathy Infection O2 Overdose Opiates Uremia Trauma Temp Thiamine Insulin Poison Psych Stroke Seizure Syncope Space lesion Shunt ```
42
When conducting PE on coma PTs, what do asymmetric findings mean? What do extensor/flexor postures mean?
Focal CNS lesion Profound CNS dysfunction
43
What is the neuroimaging modality of choice for coma PTs
Non-contrast head CT
44
What is used for hypoglycemia induced coma Tx How is inc ICP induced comas Tx
Dextrose Alcohol induced= thiamine Do not use flumazenil, risk of withdrawal Sxs ``` HOB at 30* Mannitol 0.5-1mg/kg IV Dexameth 10mg IV if tumor w/ brain edema Hyperventilate 3% hypertonic saline ```
45
What is the 5th MC Sx presenting to ED in US? Primary HAs have no ? while Secondary HAs have ?
HA 1*- no underlying cause (migraine, cluster) 2*- associated w/ underlying pathology (tumor meningitis hemorrhage)
46
HA Red Flags
Papilledema Exertion Trauma Sudden Seizure Vision Fever AMS Neuro/Neck sxs Anticoagsplatelets ImmSuppressants Recent abx No Hx Sudden change Progressive deterioration Pregnant/post-partum Lupus Behcet's Sarcoidosis
47
PTs presenting w/ HA after exertion needs to have ? DDx ruled out HAs associated w/ valsalva are associated w/ ?
Subarachnoid hemorrhage Arterial dissection of carotid/vertebrobasilar circulation Intracranial abnormality
48
? PT population are the high risk groups for HAs Why is this?
>50y/o w/ new/worsening HA Dec incidence of migraines, cluster or tension HAs w/ age increase
49
HA w/ fever suspects ? Dx When is this Dx not ruled out
CNS infection Afebrile Age extremes Tylenol/Motrin consumption
50
PTs using ? illicit drugs are at risk for bad HAs These PTs can induce ? syndrome on them self?
Coke Meth Amphtemines Reversible cerebral constriction syndrome
51
What type of FamHx is of concern for HAs
Sudden deaths Aneurysm Migraine w/ FamHx Autosomal Dom PolyKDz- inc intracranial aneurysm
52
# Define Meningisums What PE exam needs to be done?
Neck stiffness d/t infection/hemorrhage ENT for OMedia/sinusitis
53
What eye conditions can cause HAs What measurement is taken to aid/rule out one of these reasons
Scleritis Endophthalmitis Acute angle closure glaucoma Intraocular pressure >21- abnormal
54
Parts of Neuro PE
``` Mental status CN exam Pupils Motor exam Reflexes Gait/Coordination ```
55
Pts presenting w/ HA and are considered high risk get what labs drawn? Most ED PTs w/ HA get ? imaging and why?
CBC BMP Coags CSF Blood culture ESR Non-contrast CT, most sensitive for hemorrhage and signs of inc ICP
56
Why would PT w/ HA receive an MRA? What are the benefits of doing an LP?
Stenosis Congenital abnormalities Dissection CNS vasculitis Dx- meningitis, SAH, intracranial HOTN Thx- pseudotumor cerebri
57
PTs need to be in ? position when performing LP? When can you perform LP prior to imaging?
Lateral decubitus No ImmSupp Hx Normal sensorium and, No focal neuro deficits
58
What indications mean get an LP prior to imaging but don't delay ABX Tx
``` AMS Brain stem signs Focal neuro deficits Recent seizure Pre-existing neuro d/o ImmComp ```
59
What types of HA PTs need to have f/u plans
High risk- GCA, Idiopathic intracranial HTN Chronic HAs- potential abuse, over utilization of resources, repeat unnecessary images
60
What is the classic triad of meningitis When can a head CT be delayed to after LP for meningitis PTs?
HA (MC) + Fever (2nd MC), AMS, Neck stiffness ANO No Focal neuro, ImmComp, Papilledema, new onset Seizure
61
Prior to performing LP, info on what two things is important? In sequence, what are the 5 most likely microbes causing bacterial meningitis?
Bleeding status Platelets- <20K/INR 1.5 or higher= c/i ``` Strep pneumo GBS N meningitidis H influenza L monocytogenes ```
62
Where are the 5 MC microbes causing meningitis found?
``` SP- penetrating head trauma NM- dorms/barracks HI- unvaccinated LM- alcoholics, older PTs SA/Strep- post-craniotomy ```
63
How is bacterial meningitis Dx This test allows what follow on tests to be conducted?
LP ``` Gram stain Culture Cell count Glucose Protein ```
64
Lect 2 Slide
33 table
65
How is bacterial meningitis Tx
``` ABCs, rainbow labs, culture Empiric ABXs Non contrast head CT LP Admit w/ droplet isolation ```
66
Why are SAHs so dangerous? 75% of these are caused by ?
50% survive 30 days Ruptures aneurysms
67
What are the RFs for SAH in AD Pts What is the first step in evaluating suspected case?
FamHx Alcohol Smoking HTN Non contrast head CT, Sens best soon after Sxs Spec best 6-12hr after Sxss
68
If suspected SAH has negative CT, what is the next step? Why is this step helpful?
LP for blood/xanthochromia- yellow appearance of CSF from enzyme breakdown of blood by bilirubin Normal CT, no xantho/RBCs= excluded SAH
69
SAHs have the greatest risk for rebleeding when? How is this reduced/mitigated? What two are NOT used for control?
First 24hrs Labetolol Nicardipine Nitroprusside Nitroglycerine
70
What is the MC occurrence 2d-3wks after SAH? All SAH PTs are admitted to ? w/ ? consult
Vasospasm ICU w/ neurosurgeon consult
71
Subdural hematomas are supplied by blood from ? Epidural hematomas are supplied from ?
Venous sources Fast arterial bleeds LoC, lucid
72
All PTs that are on anticoag/platelets and are presenting w/ HA receive ? test Intracranial hemorrhages can occur w/out TraumaHx in ? PTs
Head CT Elderly Alcohol/Substance abuse Anti-platelet/coags
73
PTs w/ ? duo of Sxs are pre-Dx w/ cerebellar hemorrhage until proven otherwise What causes brain tumor HAs?
Acute HA and vestibular Sxs (vertigo/ataxia) CSF flow obstructions Intracranial HTN
74
What are the clinical S/Sxs of brain tumors What is the imaging study of choice?
``` HA worse w/ valsalva Mental status change Wakes from sleep Abnormal neuro exam Recent Ca Dx Seizures ``` MRI w/ and w/out gadolinium
75
What are MRIs w/ contrast preferred for viewing brain tumors over CT? When are PTs considered to have Cerebral Venous Thrombosis? How can these present?
CT fails to pick up small masses ``` New HA and: Female Peripartum Recent SurgHx Hypercoag states ``` Slowly develop to thunderclap
76
How are cerebral venous thrombosis definitively Dx if CT, neural exam and mental status are all normal? What PE finding should increase suspicion?
MR Venography Inc opening LP pressure
77
How do Posterior Reversible Encephalopthy Syndromes present? What usually causes this? What PTs is it MC to occur in?
Severe HA Vision changes Ecephalopathy HTN ImmSupp ImmModulators Chemo End stage renal Dz
78
How is Posterior Reversible Encephalopthy Syndrome Dx This Dx is considered when ? Dx is r/o? What are two proposed etiologies that lead to how is it Tx
MRA- image of choice SAH Coke/Amphetamines BP control
79
How does Posterior Reversible Encephalopthy Syndrome present? What are the key features leading to Dx
Thunderclap w/out SAH Severe HA Seizure/focal neuro deficit Multiple constrictions on angiography 2-3wks after Sxs begin
80
How does GCA present What two things need to be checked in these PTs
Fatigue Fever Proximal muscle weakness Jaw claudication Transient visual loss ESR IOP to r/o glaucoma
81
How is GCA Tx For Dx, 3 of what 5 criteria need to be met
Prednisone 60mg ``` 50y/o or older New HA Abnormal temporal artery ESR 50mm or higher Abnormal biopsy ```
82
What is the MC non-life threatening HA seen in the ER? How do these PTs present and w/ ? characteristics?
Migraines Mod/sev intensity x 4-72hrs Unilateral, pulsatile Photo/phonophobia Worse w/ activity
83
What are the MC migraine aura Sxs When does migraine occurrence peak and in ? gender
Light headed and visual changes (scotoma, scintillations) Peak 40y/o F>M
84
How are migraines Tx Benzo/opiates are only considered for HA Tx when?
Triptans- abortive agents IV hydration, NSAIDs, anti-emetics, antihistamine Steroids reduce rebounds Standard Tx failure
85
How are migraines during pregnancy Tx? What 3 classes can't be used?
NO Triptan CCS Opioid Metoclopramide Acetaminophen can be used No triptans No NSAIDs after 3rd-T No ergotamines (caffeine/isometheptene combo)
86
What is prescribed for migraine PTs upon discharge? Idiopathic Intracranial HTN is AKA and is MC in ? PTs
Abortive meds Pseudotomor cerebri Obese women 20-44y/o
87
How does Idiopathic Intracranial HTN present What can happen if this is left un-Tx?
Transient visual disturbance Back pain Pulsatile tinnitus HA Permanent visual impairment
88
How is Idiopathic Intracranial HTN Dx What is necessary for Dx
Pappilledema w/ normal neuro exam Inc opening pressure on LP (>25cm w/ normal CSF) LP- Dx and Thx w/ 1mL CSF dec= 1cm dec of pressure
89
If Pt presents w/ absent papilledema or abducens nerve palsy, how can a Dx of Idiopathic Intracranial HTN be made?
3 of: Empty sella Flat posterior aspect of globe Distented perioptic subarachnoid space Transverse venous sinus stenosis
90
What med can be used to help lower ICP in PTs w/ Idiopathic Intracranial HTN How do cluster HAs present What is a distinguishing feature of these types of HA
Acetazolamide w/ Opto/Neuro guidance and consult Later in day in males w/ ipsilateral Sxs- lacrimation Worse w/ alcohol PT needs to pace
91
Cluster HAs can mimic ? issue What criteria is needed to dx
Dental pain ``` Circadian Unilateral Time 15-180min Severe w/ one: Ptosis Edema on face Nasal congestion Conjunctival injection Lacrimation Sweating ```
92
How are cluster HAs Tx Stokes occurring at ? location shuts off blood supply to whole brain?
100% O2 12L/min x 15min via NRB mask Sumatriptan 6mg SC Temporopolar artery
93
The actual injury from a stroke is due to ? What subsequent results can exacerbate an initial stroke?
Loss of O2 and glucose needed for phosphate production Edema Mass effects
94
What are the two categories and subsequent types of strokes What type of strokes are common causes of TIAs?
Ischemic- MC Thrombotic Hypoperfusion Embolic Hemorrhagic- Intracerebral Subarachnoid Ischemic- thrombotic
95
Thrombotic Stroke mechanism and notes Emoblic stroke mechanism and notes Hypoperfusion stroke mechanism and notes
Narrowing of damages lumen by in situ process- clots Gradual onset that can wax/wane Obstruction of normal lumen by material from remote source Sudden onset, 1/5 of ischemic strokes Low blood flow leading to hypoperfusion of brain Diffuse injury in watershed areas Sxs may wax/wane
96
Intracerebral strokes mechanism and notes Non-traumatic subarachnoid stroke mechanisms and notes
Intraparenchymal hemorrhage from weakened arterioles Inc ICP causes neuro damage Secondary constriction causes perfusion changes Hemorrhage into sub-arachnoid space Preceded by sentinal HA- warning leak
97
Intracerebral strokes are more common in ? PT populations What is the critical component to stroke prehospital care?
Asian/Africans Time
98
Clinical features of strokes What score system is used
Facial droop Arm drift Abnormal speech Cincinnati prehospital scale
99
What is the traditional Sx of stroke seen in female PTs What is the non-traditional Sx of stroke seen in female PTs What is a non-traditional Sx seen in both genders?
Sudden AMS Generalized weakness Sudden hiccups
100
What is the timing of Sxs in embolic/hemorrhagic stroke What is the timing of Sxs seen in thrombotic/hypoperfustion strokes? What is the timing seen in cerebral aneurysm ruptures/ What is the timing seen in cervical artery dissection?
Sudden onset Wax/wane Valsalva w/ immediate HA/sudden onset when lifting Recent neck trauma/manipulation
101
RFs for thrombus strokes RFs for embolus strokes
HTN DM Atherosclerotic dz Transient neuro deficit Afib Valve replacement Recent MI Transient neuro deficit
102
Time of stroke Sxs is paramount and starts when? Define stroke imitator Todd's Paralysis
Time of last known baseline/normal Transient paralysis after seizure that dissipates