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25 Cards in this Set

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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:
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
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
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
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
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
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
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
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
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
Acute hemorrhage
– Subdural hematom
- Epidural Hematoma
- Intracerebral Hemorrhage
- Subarachnoid Hemorrhage
- Mass lesions- Tumors
-Hydrocephalus
-Brain Abscess
Lumbar Puncture (LP) can show
CNS infections like meningitis & encephalitis

& subarachnoid hemhorrage (by the presence of xanthochromia/rbc [yellow spinal fluid])
Differential Diagnosis: AEIOU-TIPS
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