L3: AMS + Toxicology Flashcards by Jeri Sheldon (AZ PA Mast 20)

If you don’t ask person, place, and time, what should document about someone’s mental status?

Alert and appropriate

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Alert is defined as

Awake, fully aware of surroundings, appropriate response to normal stimuli
Does not imply capacity to focus attention

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Spectrum of level of conciousness

alert
lethargic/somnolent
obtunded
stuporous/semicomatose
comatose

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Lethargic or somnolent is defined as

not fully alert, drifts off to sleep when not stimulated, spontaneous movements decreased, awareness limited

Unable to pay close attention, loses train of thought

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Obtunded is defined as

Difficult to arouse and when aroused, confused

Constant stimulation required to elicit minimal cooperation

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Stuporous or semicomatose means

Does not arouse spontaneously

Vigorous stimulation→ little response, moaning/mumbling when aroused

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Coma

unarousable unresponsiveness

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When to intubate someone according to the glasgow coma scale

Score <8 for >72 hours

very poor prognosis

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Major neurocognitive disorder aka

Dementia

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Major neurocognitive disorder diagnosis per DSM 5

Evidence of significant cognitive decline in at least one domain:
learning + memory, language, executive function, complex attention, perceptual motor function, social cognition

Impairment is acquired + a significant decline from previous functioning

Interferes with independence in everyday activities

Not exclusively in context of delirium

Not better explained by another mental disorder

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Delirium diagnosis per DSM 5

Disturbance in attention + awareness

Develops over a short period of time, represents a change from baseline, fluctuates throughout day

Additional disturbance in cognition→ memory deficit, disorientation, language, visuospatial ability, perception

Spectrum: drowsy/lethargic vs agitated and confused, visual hallucinations, tremulousness, myoclonus/asterixis

Not better explained by a different neurocognitive disorder and isn’t due to severely reduced level of arousal such as coma

Evidence that disturbance is caused by a medical condition, substance intoxication/withdrawal, or medication side effect

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How prevalent is delirium?

What are its complications?

30% of older patients experience delirium, usually while hospitalized

Doubles morbidity + mortality of a medical condition

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Factors that increase risk of delirium

Underlying brain disease → dementia, stroke, Parkinson’s

Age >80

M>F

Infection, fracture, medical problems

Polypharmacy

ETOH use

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Possible cardiac etiologies of AMS

Acute coronary syndrome
cardiac arrhythmia
hypertensive encephalopathy

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Possible pulmonary etiologies of AMS

Pneumonia
pulmonary embolism
hypoxia
hypercarbia

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Possible metabolic etiologies of AMS

Hyponatremia
hypercalcemia
renal failure
thyroid disorder
hypoglycemia

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Possible infectious etiologies of AMS

Pneumonia
UTI
meningitis
bacteremia

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Possible neurologic etiologies of AMS

CVA
encephalopathy
meningitis/encephalitis
seizure
malignancy
intracranial hemorrhage
spinal cord injury

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Possible psychiatric etiologies of AMS

Dementia
delirium
Wernicke’s encephalopathy
conversion disorders

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“Other” possible etiologies of AMS

Alcohol or benzodiazepine withdrawal
medication/drug effect
shock
post-op state

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AEIOU-TIPS acronym for common etiologies of AMS

Alcohol
Epilepsy/Endocrine/Exocrine/Electrolyte
Infection
Overdose, opioids, oxygen deprivation
Uremia
Trauma, Temperature, Toxins
Insulin
Psychosis
Stroke, Shock

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MOVE STUPID acronym for common etiologies of AMS

Metabolic→ hyponatremia, hypernatremia, hypercalcemia
Oxygen→ hypoxia
Vascular→ CVA, bleed, MI, CHF
Endocrine→ hypoglycemia, thyroid
Seizure→ postictal state
Trauma, Temperature, Toxins
Uremia
Psychogenic
Infection
Drugs→ intoxication or withdrawal

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The first interventions you should do for all patients with AMS

O2
finger stick glucose
EKG
place IV/draw labs

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The initial workup for AMS should include

Serum electrolytes
creatinine
glucose
calcium
CBC
UA
pregnancy test
TSH, Folate, B12
\+/- blood alcohol, urine drug screen, specific drug levels

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If a patient with AMS has CAD or is older than 50 years

ECG

If a patient with AMS has respiratory symptoms or a fever

CXR

If a patient with AMS has focal neurological exam findings or history of trauma

Head CT

If an AMS patient has a negative head CT, but you're still super suspicious

MRI brain or EEG

If a patient with AMS is hypoxic, or you suspect metabolic acidodis

ABGs

If you suspect meningitis or encephalitis in a patient with AMS

Lumbar puncture

Medical interventions you can give to any AMS patient that won't cause them harm if it isn't the cause of their AMS

folate dextrose naloxone

If a patient with AMS is really aggressive....

Physical restraints are a LAST RESORT Use frequent touch, reassurance and verbal orientation from familiar persons

If a patient with AMS has potential to harm themselves or others

psychotropic medication trial: | low dose haloperidol

Benzos + AMS

avoid UNLESS: sedative drug/alcohol withdrawal sympathomimetic or anticholinergic poisonings

Cholinesterase inhibitors + AMS

rivastigmine, donepezil Avoid not effective, bad side effects

Your patient was working in the garage: what kind of poisoning?

Carbon monoxide

Your patient was fumigating a ship: what kind of poisoning?

Cyanide

Your patient was applying chemical to crops: what kind of poisoning?

Organophosphates

Physiological excitation

CNS stimulation | Elevated HR, BP, RR, temp

Physiological depression

Depressed mental status and reductions in HR, BP, RR, temp

Mixed physiologic effects

Polydrug ODs exposure to metabolic poisons heavy metals Agents with multiples MOAs

Exposures that cause physiological excitation

Anticholinergics Sympathomimetics Central hallucinogen drugs ETOH withdrawal

Exposures that cause physiological depression

``` ETOH, methanol, ethylene glycol Sedative hypnotics Opiates Cholinergics Sympatholytics ```

Exposures that cause mixed physiologic effects

``` Metformin Sulfonylurea ASA Iron Cyanide Mixing of street drugs ```

Example anticholinergics

diphenhydramine dextromethorphan atropine some antidepressants

Example sympathomimetics

cocaine meth bath salts epi/NE

Example sedative hypnotics

benzodiazepines | barbiturates

Example cholinergics

organophosphates

Example sympatholytics

Clonidine | alpha and beta blockers

Topical decontamination

Copious water or saline irrigation

Ingestion decontamination

``` activated charcoal gastric lavage whole bowel irrigation endoscopy surgery dilution cathartics ```

Enhanced elimination methods

forced diuresis urine ion trapping hemodialysis exchange transfusion

Flumezenil

benzos antidote | caution: can cause seizures in chronic benzodiazepine patients

Possible MOAs of antidotes

Prevent absorption Bind and neutralize poisons directly Antagonize end-organ effects Inhibit conversion to more toxic metabolites

If the antidote has a shorter half life than the toxin (ex: naloxone)

Toxicity may reoccur | Prevent using repeated administration or IV dosing

Get these labs for ALL poisonings, toxidromes, and AMS

Serum pregnancy test Fingerstick glucose **Acetaminophen and Salicylate testing**

Anticholinergic toxidrome presentation

"Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone and the heart runs alone" ``` Hyperthermia dry flushed skin dilated pupils agitation hallucinations delirium tachycardia (earliest/most reliable sign but nonspecific), HTN Urinary retention decreased bowel sounds seizures (rare) ```

Anticholinergic toxidrome diagnosis

clinical | serum drug levels are not helpful

Anticholinergic toxidrome treatment

Agitation→ benzos Relatively recent ingestion→ activated charcoal *Patient must have normal mental status and ability to protect their airway* Moderate to severe poisoning→ +- Physostigmine

Sympathomimetic toxidrome presentation

``` Hyperthermia tachycardia/dysrhythmia HTN diaphoresis agitation hallucinations paranoia dilated pupils seizures *Appears similar to alcohol withdrawal* ```

Sympathomimetic toxidrome treatment

Supportive care | Benzos

Anticholinergic vs Sympathomimetic: bowel sounds

Anticholinergic: hypoactive Sympathomimetic: hyperactive

Anticholinergic vs Sympathomimetic: skin

Anticholinergic: dry, dry mucous membranes Sympathomimetic: diaphoresis

Opioid toxidrome presentation

``` Hypothermia bradycardia hypotension bradypnea/apnea flash pulmonary edema CNS depression coma miosis ```

Opioid toxidrome treatment

Supportive care +/- Naloxone (Narcan)

Naloxone (Narcan)

opioid antagonist, duration of action 45 mins→ repeat dosing/continuous IV Chronic narcotic users that are breathing→ small dose .4 mg→ avoid precipitating withdrawal

Sedative-hypnotic toxidrome presentation

``` Hypothermia normal vitals or bradycardia/ hypotension bradypnea/apnea CNS depression coma hyporeflexia *variable pupils* ```

Sedative-hypnotic toxidrome treatment

Supportive care Tincture of time +/- flumazenil (rare, induces seizures in chronic benzo users)