Exam 2 ALTERED MENTAL STATUS

Question 1

Levels of Consciousness? (5)

Answer 1

Alert
Lethargic/Solemn
Obtunded
Stupor
Coma

Question 2

Alertness includes?

Doesn’t include?

Answer 2

awake and aware,
N response to stimuli

Ability to focus attention

Question 3

ABCD of initial eval?

Answer 3

Airway
Breathing
Circulation
Dextrose (get FSBS)

Question 4

AVPU is?

Answer 4

Neuro test:

Alert, Verbal, Painful, Unresponsive

Question 5

Initial intervention for coma includes? (3)

Answer 5

O2
IV access/Fluid resuscitation
Coma Cocktail:
Thiamine + D50W + Naloxone

Question 6

Coma Cocktail response tells us?

Answer 6

If wakes w/i 2-3 min = hypogly or opiate OD

No response = keep looking

Question 7

Labs for coma? (8)

Answer 7

ABG
BAL
Blood CX
CBC
CMP
CSF
Drug screen
UA

Question 8

Studies for coma? (3)

Answer 8

EKG
CXR
CT

Question 9

Physical exam for coma includes? (8)

Answer 9

Vitals repeated often

Order of exam:
Skin (temp, text, tracks)
Neck (meningeal, JVD)
Chest (breath, heart, wall integrity)
Abd
Extrem (stable pelvis, movement)
Neuro (GCS, CNs, reflex, pupils, anal sphincter)
Psych

Question 10

Breath odors tell us:

Fruity?

Bitter almond?

Rotten eggs?

Oil/Gas?

Fluor green, no odor?

Answer 10

Fruity = DKA, Nitrites, isoprop alcohol

Bitter almond = cyanide

Rotten eggs = hydrogen sulfide

Oil/Gas = hydrocarbons

Fluor green, no odor = ethylene glycol

Question 11

Cholingergic Poisoning:

Caused by?

Sx onset?

Results in?

Tx?

Answer 11

Cause: organophos, nn gas, mushrooms

Onset: 8 hrs

Results: seizure, coma, resp/card fail

Tx: 2-PAM or Atrophine

Question 12

Cholingergic Poisoning: Presentation?

Answer 12

DUMBELS

Defection
Urination
MM weakness
Bradycard, Bronchorrhea, Bronchospasm
Emesis
Lacrimation
Salivation

Question 13

Anticholingergic Poisoning:

Caused by?

Tx?

Answer 13

Causes: TCA, Antipsych, Antihist, Jimson weed

Tx: monitor/support

Question 14

Anticholingergic Poisoning: Presentation?

Answer 14

Hot as a hare (fever)
Blind as a bat (mydriasis)
Dry as a bone (↓BS, urine retent, dry muc mem)
Red as a beet (flushing)
Mad as a hatter (toxic psychosis)

Question 15

TCA Poisoning:

Presentation?

Tx?

Answer 15

Pulmonary edema
Antichol sxs
AV block (Na/K chan block)
HypoTN
Confusion, Halluc, Seizure, Coma

EKG monitor
Activate charcoal
Sodium bicarb
BZs

Question 16

Opioid Poisoning:

Presentation?

Tx?

Answer 16

CNS depr, miosis, resp depress

Vent support, Naloxone

Question 17

Sympathomimetic Poisoning:

Caused by?

Presentation?

Tx?

Answer 17

Cocaine, Meth

Psychomotor agitation, mydriasis, diaphoresis, tachy, HTN, rhabdomyolysis, MI

Cooling, sedation, hydration

Question 18

Antidotes:

Acetaminophen?

Antichol?

BZs?

β-block?

CCB?

Digoxin?

Heavy metals?

Narcotics?

Answer 18

Acetaminophen = acetylcystine

Antichol = physostigmine

BZs = Flumazenil (Ramazicon)

β-block = glucagon

CCB = Ca2+

Digoxin = Digibind

Heavy metals = chelation

Narcotics = Naloxone

Question 19

Sedative-Hypnotic W/D caused by?

Answer 19

BZs and barbs

Result of abrupt stop after long use or high doses

Question 20

Sedative-Hypnotic W/D presentation?

Answer 20

Agitiation
Tremor
N/V
Tachy
Hallucinations
Flushing

Question 21

Sedative-Hypnotic W/D tx?

Answer 21

Short-acting barb then long in equiv dose

Pentobarb 300mg PO or 200 mg IM until aroused ->

Phenobarb PO tapered over 10 days

Question 22

Seizures from W/D caused by?

Answer 22

U earliest sign of EtOH w/d (b/w 6-48 hrs)

May become DTs

Question 23

Seizures from EtOH W/D presentation?

Answer 23

U focal
U pt still responsive to verbals
Rare loss of bowel/bladder
No post-ictal state

Question 24

Seizures from EtOH W/D tx?

Answer 24

U self-limit
Close observation 24 hrs
If repeat seizure, single dose Phenobarb or Valium
*Dilantin doesn’t work

Question 25

e- Abnormalities that cause AMS?

Presentation?

Answer 25

U hypoNa+ < 120

Delirium, drowsiness, seizure, coma

Question 26

Metabolic causes of AMS? (4)

Answer 26

Endocrine
Hepatic
Renal
Thyroid storm

Question 27

Metabolic AMS presentation?

Answer 27

Mental status flux w/ lucid periods,
No focal abnormalities
Visual halluc
Recent memory not intact

Question 28

AMS Presentation resulting from Acute Psych Disorders? (4)

Answer 28

U recent memory retention intact
Able to perform simple calculations
Auditory halluc
U a/w drug/alcohol

Question 29

Thrombotic Thrombocytopenia Purpura presentation?

Tx?

Answer 29

Acute fever, bleed/rash, renal fail, neuro ∆s
C 20-40yo F
Related to vWF

plasma exchange + steroids

Question 30

Acute head trauma rectal exam tells us?

Answer 30

If tone intact = likely intracranial injury

If ↓ or no tone = coexisting spinal cord injury

Question 31

HYPOthermia is?

Presentation?

Answer 31

Skin temp ~ 91F

Periph vasoconst
Shivering
Mental status ∆
CV ∆
Resp ∆
Apathy, Lethargy, Ataxia

Question 32

HYPERthermia is:

Exhaustion?

Answer 32

Exhau: Core temp N to < 106
Ortho hypoTN, tachy, sweating

Stroke: Core temp > 106
Same + CNS dysf

Question 33

Typical Infection AMS causes in elderly?

Infants?

Answer 33

urosepsis, PNA

meningitis, sepsis

Question 34

Inflamm causes of AMS?

Answer 34

SLE
Giant cell arteritis
Sarcoidosis

Question 35

Acute intoxication presentation?

Answer 35

Metabolic encephalopathy
Periph vasodil
Tachy
HypoTN
HYPOTHERMIA

Question 36

Acute intoxication stupor occurs at what BAL in non-chronics?

Answer 36

250-300 mg

Question 37

Wernicke’s is?

Presentation?

Tx?

Answer 37

EMERGENCY
Acute thiamine deficiency w/ carbohydrate ingestion from alcoholism, malnutrition or both

Ophthalmoplegia, nystag, ataxia, confusion,
Peripheral Neuropathy

Question 38

Wernicke’s tx?

Answer 38

Thiamine IV (P) + Mg
Rest to protect CV

Question 39

DT’s are?

Presentation?

Answer 39

LIFE THREATENING
From EtOH w/d (3-4 days post)

Significant delirium w/ tremors, agitiation,
Purposeless activity,
Visual halluc,
Tachy,
Dilated pupils
Fever, Sweating

Question 40

DT tx? (4)

Answer 40

Thiamine IV/IM
Fluids
Vit C/B
Librium to prevent seizures