Lecture 14: AMS + Psych Emergencies Flashcards
() is slow in onset and chronic in nature
Dementia
() is an acute change in attention and mental functioning
Delirium
If a patient presents with neuro deficits and AMS, the first thing you focus on is…
their LOC
If you have an AMS patient that is also hypoxic, you should probably order a ()
ABG
The main restriction to using a simple mask or NRB over NC is (time)
NRB and simple mask can only be used for a few hrs.
There are 3 things you can administer IV for an AMS patient that are pretty much 0 risk. They are:
- Dextrose
- Thiamine
- Naloxone
You have treated the pt’s vitals and started 2 large bore IVs. They are currently stable. Your next step is to…
Obtain history
Very abrupt onset of AMS is most likely () or () or seizures.
Ischemia or SAH
Associated symptoms in a neuro history
Have fun
GCS scale (better know this)
- EYES: spontaneous, verbal, pain, none
- VERBAL: oriented, confused, weird responses, weird SOUNDS, none
- Motor: Obeys, Goes towards pain, withdraws from pain, Decorticate, Decerebrate, None
Decorticate = protect the core
A neuro deficit usually suggests a () abnormality of the brain
Structural
What lab measure serum ketones?
Serum-beta-hydroxybutyrate
You suspect SAH but CT non-con was negative. Your next test is a ()
LP
Delirium generally occurs over ()
Hours-days
The two agents used for acutely agitated delirious patients are:
- Haldol PO/IM (monitor for EPS and QT prolongation)
- Ativan PO/IM/IV (monitor for resp depression)
Haldol is an antipsychotic. Ativan is a benzo
Same tx for dementia pts with dangerous behaviors
Prior to discharging someone you gave Narcan to, you should observe them for ()
1-1.5 hours!
Narcan has a shorter half-life than some opiates.
Also consult psych if it was accidental. Intentional OD = SI attempt
Hypoglycemia is < () in symptomatic children and < () in asymptomatic children
- < 45 if symptomatic
- < 35 if asymptomatic
Neonates with hypoglycemia get () over 3-5 minutes, whereas Infants and Older children get () over 3-5 minutes. Maintenance dosing is with ()
All dextrose %s
- Neonates: D10W
- Infants/older children = D25W
- Maintenance = D10W
Glucagon if no IV access
In adults, hypoglycemia is treated with (dextrose %) over 3-5 minutes and with a continuous infusion of (dextrose %)
- D50W for adults
- D10W for maintenance to keep > 100
Glucagon for no IV
() is used for hypoglycemia that is refractory and related to (diabetic drug) use
Octreotide to counter sulfonylurea usage
SC injection
T/F: You should remove insulin pumps if a patient is becoming hypoglycemic
False. Consult endo to lower tha basal rate.
Generally, the only people that need to be admitted for hypoglycemia are those on (drugs)
Sulfonylureas, long acting glucose or meglitinides for serial glucose monitoring
Insulin has 5 main actions:
- () into cells
- () into cells
- () environment
- Inhibits the breakdown of ()
- Inhibits the breakdown of ()
- Glucose into cells
- K+ into cells
- Anabolic environment
- Inhibits fat breakdown
- Inhibits protein breakdown
DKA is more common in type (1/2) diabetics
Type 1!
The 6 Is of DKA are:
- Infection
- Infarction
- Insult (to the body)
- Infant (pregnancy)
- Indiscretion (lack of care)
- Insulin (absence
Of hyperglycemia, volume depletion, and acidosis, the first symptoms will be from…
Hyperglycemia
DKA
The diagnostic criteria:
- BG > () mg/dL
- Anion Gap > () to ()
- Bicarb < ()
- pH < () with moderate ketonuria or ketonemia
- BG > 250
- AG > 10-12
- Bicarb < 15
- pH < 7.3
You shoulder order an EKG in a DKA patient in in order to check if they are having a () or if they have ()
- MI
- Hyperkalemia
RFs for DKA with initial BG of < 250
The very first step of DKA management is…
Fluid resuscitation!!!!
Potassium correction in DKA is divided into 3 sections:
- If K > 5.2, you use ()
- If K is 3.3-5.2, you use () with ()
- If K is < 3.3, you use ()
- > 5.2 = only need insulin.
- 3.3-5.2 = 20-30 mEq of K to each LITER of NS + insulin
- < 3.3 = only need K
Once volume status is corrected and potassium is being corrected, your next step in management of DKA is…
Insulin therapy
0.1 and 0.1 units per kg if you bolus, otherwise 0.14 units per kg
The first infusion of insulin you give in DKA is primarily to treat what?
Potassium levels
The goal glucose reduction rate per hour in DKA is… ()
75 mg/dl/hr
Your patient in DKA needs glucose reduction. They started at 250, but after one hour, they’re at 240 even with an insulin drip. They weigh 70 kg. You should give (amt) of insulin via (bolus/drip)
9.8 units of insulin BOLUS
70 kg * 0.14 Units/kg
Your patient in DKA needs glucose reduction. They started at 450, but after one hour, they’re at 350 with an insulin drip. They weigh 70 kg. You should do what next???
Halve their insulin drip
Your patient in DKA is being glucose monitored. They started at 275, and after one hour, they’re now at 200 with an insulin drip. They weigh 70 kg. You should switch their fluids to () and decrease their insulin dose to ()
- Switch fluids to D5NS
- Decrease insulin to 1.4-3.5 Units/hr
Electrolytes, AG, and ABG/VBG should be rechecked every () hours in DKA.
Every 2 hours
In a pH of less than 6.9 in DKA, you can consider giving () in water with K+ until pH is at least 7.
Bicarb
But just consider.
The MC type of CVA is a…
Ischemic CVA
The most important thing to know in history for a CVA is…
Last known normal time
The goal time for a NON-con head CT to be done for a CVA is… () minutes of arrival. It is most sensitive within () hours.
- 25 minutes upon arrival
- 6 hours is highest sens
The normal position for a stroke patient is…
Supine
Antipyretics are only indicated in CVA if temperature is greater than…
100.4F/38C
In an ICH with an SBP of 150-220, you should lower their SBP to () within () hours
Goal of 140 SBP in 1 hour
In an ICH with an SBP > 220, you want to get their SBP down to ()
140-160 SBP
The 3 first-line antiHTNs for lowering BP in a CVA are…
- Labetalol
- Nicardipine
- Clevidipine
In order for tPA to be administered for an ischemic stroke, SBP must be below () and DBP must be below ()
- SBP <= 185
- DBP <= 110
Labetalol, nicardipine, clevidipine
In an ischemic stroke that is not eligible for tPA, the goal SBP and DBP are
Only treat if > 220/120 or signs of end-organ damage.
Labetalol, nicardipine, clevidipine
tPA can only be used in a () stroke, within () hours of symptom onset, and a patient older than () years
- Ischemic stroke
- 4.5 hours of onset
- 18 years or older
Also get informed consent and do exclusion criteria
tPA is administered to your ischemic CVA patient. You need to perform neuro checks every () minutes for 3 hours and then every () for 6 hours. You also need to make sure their BP is under ()/()
- Q15 mins x 3 hours
- Q30 mins x 6 hours
- 185/105
Thrombectomy can be done if tPA is contraindicated or if a patient has a NIHSS of (less than ). It is specifically for a () artery occlusion in the () circulation with a small infarct core and non-hemorrhagic. It must occur within () hours of onset.
- NIHSS >= 6
- Large artery occlusion in anterior circulation
- Must be done within 24 hrs of symptom onset.
T/F: You should workup a TIA like a stroke
True
(Auditory/Visual) hallucinations are more suggestive of a medical etiology, whereas (Auditory/Visual) hallucinations are more suggestive of a psychiatric etiology.
- Visual = medical
- Auditory = psychiatric
Lewy Dementia = Visual hallucinations, which is a medical etiology.
T/F: UDS and BAC are necessary for awake, alert, and cooperative patients.
FALSE
You should be at least () arms lengths from a violent patient and () access to the door
- 2 arms length distance
- At least equal access to door
SAFEST approach stands for…
- Spacing
- Appearance
- Focus
- Exchange
- Stabilization (Ativan to sedate)
- Treatment
Sedation is achieved using (), whereas chemical restraint is achieved using ()
- Sedation is via ativan
- Chemical restraint is via Haldol Q30minutes
You should only use physical restraints on a patient when they pose an () or () evaluation/treatment
- IMMEDIATE threat
- Obstruct eval/treatment
Also document why
The two sets of symptoms you should monitor when administering Haldol are…
- EPS (extrapyramidal symptoms)
- QT Prolongation
Overall, the best screening approach to a suicidal patient is asking () questions
General questions about emotional state
A high risk of suicide via Assessment of Suicide risk is greater than () pts.
T/F: Males are at higher risk for suicide.
True
we r on the assessment thing
A high SI risk patient must be admitted. Involuntary admission consists of () performing an evaluation while the ED provider issues a temporary hold lasting () hours.
- Mental hygiene commissioner writes longer holds
- ED provider can write a 24-hour temporary hold.
Generally, a moderate SI risk patient is treated outpatient if:
- No () needed
- Therapy is established ()
- Development of a ()
- No medical intervention needed
- Therapy is established immediately with close follow-up
- Development of a safety plan
T/F: A “no harm/suicide prevention” contract is useful in preventing suicidal behavior
False.
() describes an agreement to treatment and proper follow-up.
Joint safety plan
T/F: Any adult can apply to have an individual involuntarily committed for homicidal ideation.
True.