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25 Cards in this Set
- Front
- Back
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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) |
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COMA
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A state of unresponsiveness, from which the patient cannot be aroused by verbal or physical stimuli to produce any meaningful response
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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 |
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SLEEP
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A state of nonpathological decreased mental status from which the patient can be easily aroused to full consciousness
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Altered Mental Status (AMS)
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Represents a spectrum of disability ranging from mild confusion to deep coma
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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 |
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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 |
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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 |
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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 |
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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) |
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Narcan (Naloxone)
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reverse effects of narcotics
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Thiamine 100mg IV
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for alcoholics (Weirneke-Korsokoff syndrome)
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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) |
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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 |
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If PE to head shows: Battles sign, Raccoon eyes, Cephalohematoma, CSF leak,Hemotympanum
This is evidence of _________ |
trauma
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fruity odor on pt's breath indicates
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ketones/acetone in DKA
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smell of almonds on breath indicates
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cyanide poisioning
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stiff neck can indicate
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meningitis
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large thyroid can indicate
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hyperthyroidism
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Acites, or hepatomegly can indicate
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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 |
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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 |
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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 |
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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]) |
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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 |
