The Approach to an Altered Mental Status in the ED Flashcards
from lecture only
the clinical state of emotional and intellectual functioning of an individual
mental status
4 types of AMS
- Confusion - behavior deemed unusual for the individual or deviates from societal norms - Confused pts are often uncooperative or combative
- Delirium - acute change in attention and mental functioning
- Dementia - slow onset of cognitive dysfunction that is chronic in nature
- Various levels of consciousness - alertness, lethargy, obtundation, stupor, coma
If diminished LOC focus on Ddx for ?
coma
If (+) neuro deficits focus on Ddx of ?
structural defects of the brain
If altered behavior in a patient who is awake, alert w/o neuro deficit, perform what exam?
MMS exam to differentiate confusion vs delirium from a psychiatric disorders
initial evaluation/approach to AMS
- VS, including O2 sat and POC glucose
- Assess for shock
- If hypoxic, consider ABG
- IV access - 2 large bore catheters preferred
- Obtain history once stable
which two forms of oxygen can be used for only a few hours?
- 6-10 LPM simple mask
- 10-15 LPM non-rebreather
coma cocktail?
- Dextrose - only if hypoglycemic (see later slide)
- Thiamine 100 mg by slow bolus injection
- Naloxone 0.4-2 mg by bolus injection
abrupt AMS think about what ddx?
ischemia, subarachnoid hemorrhage, seizure
rapid AMS think what dx?
delirium
gradual AMS think what ddx?
space occupying lesion, dementia, psychiatric disorders
fluctuating AMS think what ddx
recurring seizures, subdural hematoma, metabolic disorders, delirium
if pt has a history of similar AMS sx, think what dx?
seizures, TIA’s, delirium
SHx of Chronic alcohol use/chronic malnutrition think what dx?
Wernicke’s encephalopathy
focal neurologic changes think what dx?
structural lesion with mass effect or stroke
HA and vomiting associated sx think what dx?
intracranial hemorrhage, intracranial infection
palpitations/chest pain/SOB associated sx think what dx?
arrhythmia, pneumonia
recent confusion associated sx think what dx?
metabolic process, drug, alcohol, poison, delirium
dizziness/lightheaded associated sx think what dx?
hypotension, stroke, arrhythmia, hypoxia
Historical Keys to a Medical Cause of AMS
- Pre-existing medical problems (DM, seizure disorder)
- Absence of a known psychiatric dx
- Use of psychoactive drugs of abuse
- Use of Rx drugs w/ psychoactive properties (elderly) - Recent med changes?
- Late age of onset (>40 years)
- Presence of sx that are sudden in onset and that fluctuate over hours to days
PE approach for AMS
- Assess alertness/orientation - auditory stimulation and ability to follow commands
- Fundoscopic exam - increased ICP
- Neuro assessment
- GCS
- Children - simple observation of children - Mental status - Six-Item Screener (3 item recall; year, month, and day of week)
labs for AMS
- CBC - follow up B12, folate if applicable
- CMP, Mg
- Thyroid studies
- Coagulation profile
- Serum β-hydroxybtyrate (serum ketones); Ammonia
- Carboxyhemoglobin, ABG
- Toxicology, Blood alcohol concentration (BAC)
- Urine - UA, hCG (reproductive females)
Possible diagnostic w/u for AMS
- EKG - r/o cardiac causes (MI, arrhythmias)
- CXR - hypoxic etiologies of AMS
- Head CT w/o contrast - if focal neurologic signs, papilledema or fever
- LP with CSF analysis
- EEG - ?? in ED - consider if no other source of AMS if found or if underlying seizure disorder
Relative CI of LP?
cerebral edema, increased ICP
an acute alteration in level of consciousness with change in cognition or perceptual disturbance
delirium
presentation of delirium
- Disturbance in attention and awareness that develops over hours-days
- Fluctuation in sx x 24 hr period
- Disturbance in cognition (memory, orientation, language, perception, visuospatial)
- Sleep-wake cycles disrupted - daytime somnolence and agitation mimicking “sun-downing” at night
a slow decline in cognition involving one or more cognitive domains
learning and memory, language, executive function, complex attention, perceptual-motor, social cognition
Dementia
mgmt for delirium
- tx underlying cause
- Acute agitation - haloperidol 5-10 mg PO/IM, lorazepam 0.5-2 mg PO, IM, IV
- Admit unless cause is identified, tx initiated, and improvement seen in ED
caution with haldol?
- In elderly patients - lower dosing and inc by 1–2-mg increments q 30 min
- SE: extrapyramidal sx and QT prolongation
cautions with lorazepam?
- Lower doses for elderly patients
- SE: respiratory depression
mgmt for dementia
- Use antipsychotics (same as delirium) to control psychosis, agitation or severely disruptive or dangerous behaviors
- Admit unless has long-standing stable sx, consistent caregivers and reliable f/u
mgmt for narcotic OD
- After adequate resuscitation with Narcan, observed for 1-1.5 hrs prior to DC
- Disposition
- intentional - managed as suicide attempt
- accidental - consult psych - AMA?
definition of hypoglycemia in children?
- glucose < 45 mg/dL in sx children
- < 35 in asx
mgmt for hypoglycemic children who are Alert and w/o choking risk
juice, glucose gel/tablets
tx for hypoglycemic neonates?
D10W 5 ml/kg IV/IO/PO/NG x 3-5 min
tx for hypoglycemic infants and older children?
D25W 1-2 ml/kg IV/IO/PO/NG x 3-5 min
maintenance tx for hypoglycemic children?
D10W 6-8 mg/kg/min
if unable to get IV line, what alternative mgmt for hypoglycemia?
Glucagon IM
disposition of hypoglycemic children?
admit all children requiring ED resuscitation
Hypoglycemia in Adults
Often related to SE of ?
DM meds
mgmt for hypoglycemic adult?
-
D50W 50 mL IV x 3-5 min
- check glucose q 30 min x 2 h
- Cont. infusion of D10W to keep glu >100 -
Glucagon 1mg IM if no IV
- slower response - 7-10 min - Octreotide 50-100 µg SC if refractory 2/2 sulfonylurea
how to manage hypoglycemia for adults with insulin pump?
- Dextrose
- DO NOT remove pump - consult endo to lower pump basal rate
disposition for hypoglycemic adults?
- Admit: hypoglycemia related to long acting agents (sulfonylureas, LA insulins, meglitinides) need admitted for serial glucose monitoring
- If discharge: educate to continue carbohydrate intake and monitor glucose
Insulin has 5 main actions:
- drives glucose into cells
- drives K+ into cells
- creates an anabolic environment
- inhibits breakdown of fat
- blocks the breakdown of proteins.
what is DKA?
A life-threatening complication of DM that occurs as a result of significant insulin deficiency resulting in hyperglycemia and ketoacidosis.
DKA MC in which type of DM?
Type I
MCC of DKA?
The 6 “I’s” of DKA:
- infection
- infarction
- insult (to the body)
- infant (pregnancy)
- indiscretion (lack of care)
- insulin (absence)
3 key features of DKA
- hyperglycemia - 1st sx
- volume depletion
- acidosis
acidosis sx seen in DKA?
- Tachypnea
- Kussmaul respirations
- Fruity breath
- Abdominal pain
- Nausea/Vomiting
potentional diagnostics for DKA
- POC glucose
- CBC
- CMP + Phos, Mg
- ABG/VBG
- UA - glucose, ketones, WBC
- Serum ketones - Serum 𝛃-hydroxybutyrate
- EKG - look for MI and signs of ↑ K+
- if needed: Blood cx, Lipase
diagnostic criteria for DKA
- Blood glucose level >250
- Anion gap >10-12
- Bicarb < 15
- pH < 7.3 w/ moderate ketonuria or ketonemia
Risk factors for DKA in patients with initial glucose < 250 mg/dL
- pts presenting shortly after receiving insulin
- T1DM, young, and vomiting
- impaired gluconeogenesis - alc abuse, liver failure
- low calorie intake/starvation
- depression
- preg
- SGLT2i
step 1 of DKA tx?
Volume Resuscitation
- 2 large bore IVs w/ fluid resuscitation ASAP
- #1 with 0.9% NS 15-20 ml/kg/h for first hour
- #2 with 0.45 (½) NS TKO - After initial bolus
- Na is nml/inc: switch to ½ NS @ 250-500 ml/hr
- Na is low: keep at 0.9% NS
step 2 of DKA tx?
Correct Potassium Deficits
- K+ > 5.2 - insulin
- K+ 3.3-5.2 - 20-30 mEq of K+ to each L of NS, start insulin
- K+ < 3.3 - DC insulin, give K+ until > 3.3
step 3 of tx for DKA
Insulin Therapy
- Regular insulin ASAP (based on K+)
- 2 dosing options:
- 0.1 U/kg bolus, then 0.1 U/kg/hr OR
- 0.14 U/kg/hr w/o bolus
step 4 of tx for DKA
Recheck glucose every hour - Goal: reduce glu by 75 mg/dL/hr
- No dec by 10% after 1 h: 0.14 U/kg bolus, resume nml rate
- If glu dec >75mg/dL/h: dec drip 50%
-
When glu approaches 200:
- switch fluids to D5½ NS
- dec insulin to 0.02-0.05 U/kg/hr - Recheck lytes, AG and VBG q 2 h
- Goal: return all lytes to nml, K+ btwn 3.3-5.2
- Goal: Reduce AG and improve acid-base balance - Monitor mental status and I&O’s
for DKA if pH < 6.9 consider giving what ?
NaHCO3 in water with K+
repeat dosing q 2 hr until pH > 7.0
disposition of DKA
admit all
yer outta here!!
A sudden onset of neurologic deficit resulting from a loss of blood flow to a part of the brain resulting in brain infarction
Cerebrovascular Accident
2 types of CVA
- Ischemic CVA
- Hemorrhagic CVA
- Intracerebral
- Subarachnoid
presentation of CVA
- acute neurologic deficit: motor, sensory, coordination, mood, AMS
- Severe HA + N/V with intracranial hemorrhage: Rare hemorrhagic presentations: seizure, syncope
Most important 1 Hx piece of info for CVA?
ONSET - “Last known normal”
scoring for CVA?
NIHSS Score
diagnostics for CVA
- Non-contrast Head CT
- Lumbar puncture if concern for hemorrhagic stroke in a normal CT
- CBC, BMP/CMP, PT/INR, Troponin, EKG
- Additional labs/testing needed to evaluate your Ddx
head CT w/o contrast needs to be completed within what time of arrival for CVA?
25 minutes
possible findings on head CT for ischemic stroke?
“Normal” findings
general mgmt for CVA
- ABCs, NPO, control temp
- supine
- HOB 30° if inc ICP, aspiration risk or chronic CV/Pulm dz - manage sugar
- reverse anticoags if needed
BP mgmt for CVA - Intracerebral Hemorrhage
- HoTN - fluids
- HTN
- SBP 150-220 - goal: 140
- SBP >220 - aggressive reduction with continuous IV infusion; BP monitoring q 5 min
- SBP goal 140-160
- 1st line: labetalol, nicardipine, clevidipine
BP mgmt for ischemic stroke eligible for tPA
- BP goal of SBP ≤ 185 AND DBP ≤ 110 before tPA can be administered
- labetalol, nicardipine, clevidipine
BP mgmt for ischemic stroke not eligible for tPA
- Do not treat UNLESS SBP >220 or DBP >120 or signs of end organ damage
- TX same as AIS - labetalol, nicardipine, clevidipine
inclusion criteria for tPA?
- Clinical dx of ischemic stroke causing measurable neuro deficit
- Sx onset w/n 4.5 hrs
- ≥18 y/o
If eligible informed consent must be obtained
BP goal when tPA administered for CVA?
< 180/105
how often to monitor neuro sx for CVA pt given tPA?
- neuro checks q15m x 3 hours
- then q30 minutes x 6 hours
alt tx if rt-PA is CI or ineffective?
Endovascular mechanical thrombectomy
After rt-PA CVA pt is having persistent potentially disabling neuro deficit
next step?
Endovascular mechanical thrombectomy
considered ineffective
(NIHSS ≥6)
indications for Endovascular mechanical thrombectomy
large artery occlusion in anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)
time frame for when Endovascular mechanical thrombectomy
should be performed?
- within 24 hrs of sx onset
- at a stroke center with surgeons experienced in procedure
A transient episode of neurologic dysfunction caused by cerebral acute ischemia
Most often sx resolve within 1-2 hrs
TIA
RF for TIA
- ABCD >=4
- subacute stroke on CT
- > = 50% ipsilateral stenosis
- infarct on MRI
- recent TIA within past month
- other conditions warranting admission
- acute cardiac process, arrhythmia
- barriers to rapid outpatient
