ER-altered mental states
Terms
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- When pt presents to ER w/ altered mental state the main question to be asked is whether the AMS is due to:
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A toxic/metabolic disorder- e.g, alcohol, cocaine, heroine, perscription drugs, hypglycemia, liver disease (NH4)
Structural central nervous system disease-e.g.,alzeimers, tumor, hemherrhage
Functional disease (psychiatric) –scitzophrinia, bipolar (everything else must be cleared b4 this diagnsis) - COMA
- A state of unresponsiveness, from which the patient cannot be aroused by verbal or physical stimuli to produce any meaningful response
- STUPOR
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Unresponsiveness from which the patient can be aroused with vigorous noxious stimuli.
The stuperous patient, however, does not return a normal baseline of awareness of self or environment - SLEEP
- A state of nonpathological decreased mental status from which the patient can be easily aroused to full consciousness
- Altered Mental Status (AMS)
- Represents a spectrum of disability ranging from mild confusion to deep coma
- Initial Evaluation at ER: 1st priority
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A – Manage Airway
B – Assess Breathing
C – Circulation
Always check airway, breathing and circulation. Protect the cervical spine if there is any suspicion of trauma - Initial Evaluation: Restraints
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If pt is danger to self or other.
2 types:
1) physical (hard, soft)
2) pharmicological
***always document, and reassess frequently -
pharmicological restraints.
examples. most important. side effects/considerations -
**Haloperidol (haldol) 5-10mg IV/IM – MOST COMMON
Droperidol (inapsine) 1.25-2.5mg IV, 2.5-5mgIV – can cause torsades
Lorazepam (ativan) 1-2mg IV/IM –BENZODIAZEPINE so bad w/ etoh=respiratory depression
Use lower doses in the elderly
Cogentin or Benadryl may be used with haloperidol/droperidol to minimize extrapyramidal effects - Initial Evaluation at ER: SOA
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Brief history/physical to include brief neurological examination using Glasgow Coma Scale/AVPU
Vital signs
Cardiac Monitor
Pulse Oximeter – measures oxigen
Oxygen Supplementation
Establish Intravenous Access/Draw initial blood samples -
Initial Evaluation: Acucheck
if pt is hypoglycemic?
if pt is hyperglycemic -
if hypoglycemic treat w/ glucose/ dextrose
If Hyperglycemic Consider DKA or HyperosmolarNonketotic Syndrome(HHNK) - Narcan (Naloxone)
- reverse effects of narcotics
- Thiamine 100mg IV
- for alcoholics (Weirneke-Korsokoff syndrome)
- Flumazanil
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Not considered part of the routine
coma cocktail. Precautions in tricyclic ingestions
and patients with dependence on benzodiazepines (not used as often, can cause siezures) - History
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Onset of Symptoms (including rate of onset)
Recent complaints/symptoms
Past/Present Medical Illness
Recent Trauma
Social History (including substance abuse)
Psychiatric History(including prior suicidal
ideation or attempts)
Medications/Allergies -
If PE to head shows: Battles sign, Raccoon eyes, Cephalohematoma, CSF leak,Hemotympanum
This is evidence of _________ - trauma
- fruity odor on pt's breath indicates
- ketones/acetone in DKA
- smell of almonds on breath indicates
- cyanide poisioning
- stiff neck can indicate
- meningitis
- large thyroid can indicate
- hyperthyroidism
- Acites, or hepatomegly can indicate
- possible hepatic encephalopathy
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Glasgow Coma Score is measured by?
Lowest possible score of none for each?
Highest possible score? -
eye opening + verbal response +motor response
3
15 - Diagnostic Studies -- name 6
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Glucose
Pulse Oximetry
CBC
Electrolytes, BUN,Cr, Calcium, Mg,Phosphorus
UA
Serum and urine tox screen, Etoh level
ABG, serum osmolality
Serum therapeutic drug levels as indicated
Liver function tests/Serum ammonia
Serum osmolality
Thyroid function tests
EKG
Carboxyhemoglobin level - CT Scan of the head -- can show
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Acute hemorrhage
– Subdural hematom
- Epidural Hematoma
- Intracerebral Hemorrhage
- Subarachnoid Hemorrhage
- Mass lesions- Tumors
-Hydrocephalus
-Brain Abscess - Lumbar Puncture (LP) can show
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CNS infections like meningitis & encephalitis
& subarachnoid hemhorrage (by the presence of xanthochromia/rbc [yellow spinal fluid]) - Differential Diagnosis: AEIOU-TIPS
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A-Alcohol,drugs,toxins
E-Endocrine,Electrolytes
I -Infection
O-Oxygen,Opiates
U-Uremia,Renal
T-Trauma,Temperature
I-Insuin(DM)
P-Psychiatric,Porphyria
S-Space occupying causes (lesions,Stroke,Shock)
SAH