ALOC Flashcards Preview

Question 1

1

DDx in these pt’s is broad

Answer

i. Infection
ii. Intoxicated
iii. Confused
iv. Agitated, violent
v. Neurologic
vi. Traumatic
vii. Psychiatric

altered pts are brought for Diagnosis, protection, stabilization, intervention, disposition

Question 2

2

organic issue

Answer

= medical issue

Question 3

3

functional issue

Answer

psychiatric

Question 4

4

Disturbed level and content of consciousness

delirium or demetnia

Answer

Delirium

Delirium is a transient disorder characterized by impaired attention, perception, thinking, memory, and cognition.

Question 5

5

Gradual onset

delirium or dementia

Dementia

Answer

a. Visual hallucinations are usually not psychiatric

Answer

= Psych plus drug abuse

Answer

 Alcohol, withdrawal
 Epileptic Seizure
• Post-ictal state
 Insulin (glucose)
 Opiates, other drugs
 Uremia, liver failure
 Trauma
 Infection**
• Especially the elderly
 Psychiatric
 Shock

Answer

SICK
old/young/immunocompramisEd

PE findings:
falls, trauma
rash stiff neck
focal neuro

evidence or hx of seizure

toxidrome

PMHhx

meds

Answer

rapid onset
disorientation
memory loss
flucuaing ALOC
social immodesty
sxs worse a night
VISUAL HALLUCINATION
don't forget ETOH w/d

Answer

pulse ox
d stick
upreg
u tox
ETOH level
bowel sounds
tachy-EKG
pupils
temperature

CAN you reverse it with NARCAN or Glucose?

Answer

what do you see
hear from EMS
5150
past visits to ED
do they have DMC?

Answer

what happened?
pain?
sick?
medical problems?
fall trauma?
meds?
are you taking them?
have you used drugs or alcohol today?
ORIETNATIon ?s

Answer

see anything unusual?
orientation?

do you know where you are?

do you know the date?
months?
year?

who is the president?

Answer

mechanism
when? once or ore?
did you lose consciousness
what did you do after it happened?
how do you feel now?
what hurts?
HA? vomiting?
can you walk?

Answer

onset fast or slow?
how different from normal?
happened before?
PMHx? meds ? psych hx?
recent illness or trauma?
witnessed LOC?
drus?
etoh?
delusions or paronia?
recent emotional stress?
hx of suicide attempts?
anything that could help me?

Answer

vitals: EMS, triage, repeat

appearance, undress heat to toe

get permission, explain, go slow
look for toxidrome

GCS

Answer

7-9 is significant
dead people get a 3
document

Answer

eye opening (4)
verbal (5)
motor (6)

Answer

spontaneous
to voice
to pain
none

Answer

oriented
confused
inappropriate
incomprehensible
none

Answer

obeys commands
localizes
withdraws
flexes
extends to pain
none

Answer

awake
verbal
pain
unresponsive

Answer

Vitals
d stick
pulse ox
upreg
urinte tox
etoh

Answer

blood
infections
ketones

Answer

– rhabdomyolysis (agitated, stimulants, down time)

Answer

ETOH involvement

Answer

Tylenol, ASA level

Answer

seizure meds
digoxin

Answer

cbc
chem
CK
mag phos
tylenol
ASA
med levels
HIV
TSH (myxedema)
RPR neurosphililis

Answer

Consider lactic acid if fever, hypotension

Answer

Agitated, delirium, alcohol, tox: all are not eating/caring for self

Answer

IM

benzos-versed 2-5 mg

geodon 10-20mg
zyprexa-voices 5mg

visit these pts regularly!!!

Answer

versed 2-4mg IV

Answer

10-20 mg can give iM
for psych pt

Answer

monitor VS and mental status changes

recognize if getting worse or better

Answer

LP= fever and ALOC
HIV and ALOC
CA and ALOC
new delirium or new psychosis

CT- traumatic ALOC
new delirium w/o cause or any new psychosis

HIV, CA+ALOC =CT

Answer

ED “medically clears” pt’s on 5150 hold

1. ED must determine there is no medical/organic cause

2.Psych facility is not an acute medical facility!

1. Can be discharged home
2. Need medical admission
3. Need psychiatric admission

Answer

dx has been established and pt is stable for transfer

pt is able to talk to a psychiatrist
sedated.intoxicated can't be evaluate

Practitioner to practitioner transfer by phone

inform pt and family

Answer

1. Do you want to hurt yourself or anyone else?

2. Are you feeling suicidal now?

3. Have you thought about how you would do it?

4. Do you have: gun, access to pills, etc…?

5.Have you ever tried to hurt yourself before?

6. Are you hearing voices? What are they saying?

7. Are you seeing anything unusual?

Answer

AH = auditory hallucination

VH = visual hallucinations; SI = suicidal ideations; HI = homicidal ideations

Answer

i. Vitals

ii. General appearance

iii. Head to toe exam – get permission

iv. Orientation questions, Mini-Mental Status if able

v. Document if pt is unable or unwilling to cooperate with exam and why

vi. May need to examine after sedation

vii. Serial exams

Answer

no previous psych
>40 -first psych issue
abnormal vital signs
impaired consciousness
recent memory loss, trauma
impaired consciousness
focal neuro finding

Answer

d stick
upreg
utox

Answer

Soft restraints, leathers, belts, mask

Answer

benzos )

antipsychotics

Answer

midazolam (versed) 2-5mg IM/IV
lorazepam (ativan) 1-2mg IM/IV

Answer

ziprasidone (geodon) 10-20mg IM/IV 20 mg PO

Haloperidol(haldol) 2-5mg IM/IV
add congentin 1-2mg IM/IV

Answer

1. Must have legitimate reason to restrain, must fill out form
2. Restrain pt’s with other staff assisting
3. Remove restraints with other staff present
4. Never remove restraints from any patient you do not know
5. Restrained pt’s must be supervised
6. Contracts with patients - be
7. Speak to the family about restraints

Answer

1. Male, white, unemployed, single
2. Adolescents
3. Drug and/or alcohol abuse
4. Recent life stressor
5. Physical/chronic illness
6. Hx domestic violence, sexual assault/abuse
7. Major mood disorders, 10% schizophrenic pts
8. Lethality/Rescue ratio of plan
9. Past attempt, family Hx of suicide

Answer

1.Recognition, assess risk, 5150?

2.Suicide precautions in ED
a. Restraints, high visibility area, “clean” area

3. Medically clear
a. Monitor, treat, consider overdose
b. Repair lacerations, hydrate, etc...

4.Psychiatric consult by phone or in person
5. Admit to hospital or transfer to psych facility
a. Transfers must be stable!

Answer

1. Psychiatric/Attending MD consultation obtained

2. Not suicidal now

3. Risk profile low

4. Intent, gesture for secondary gain

5.Pt has family, friends here, now

6. Pt has stable home environment

7. Can f/u with psychiatrist reliably

8. Means of lethality eliminated or regulated

Answer

DEPRESSION

Answer

 Sadness
 Insomnia/Hypersomnia
 Guilt
 Mood
 Energy
 Concentration
 Appetite, activity
 Pleasure (anhedonia)
 Suicide

Answer

Organic or Functional or Situational?

– “I can’t visit my grandkids b/c my COPD has gotten really bad”-Organic

Answer

b. ED rarely initiates medical therapy (2 week rule – takes about 2 weeks for any antidepressant to work)

Discuss therapies – drugs help, medical model

Answer

“Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week”

Answer

ii. Psychiatric, medical, medications, drugs

iii. Patient a danger to themselves/others?

iv. Protect patient, protect staff

often start with benzos in these cases

Answer

1. Chemical restraint often needed – Benzo’s

v. Good history/PE - get info

vi. Medical work-up if new, unstable

---> ALOC Protocol, add EKG (often tachycardic), TSH, CK

need a CK and TSH because rhabdomyolisis happens when there is an inability to care for themselves and TSH for a hyperthyroid issue

Answer

feel that they are infested with bugs or some sort of unusual virus; meth disease

Answer

need to think about what is really going on with this patient

Cardiac - MI, CHF, dysrhythmias (afib)

Endocrine – thyroid, etc

Respiratory - PE (all have anxiety), asthma, COPD

Drugs-

"i'm not finding a medical problem tonight"

Answer

1. Sympathomimetics, caffeine, herbals, cannabis, LSD, ecstasy, benzo’s w/d!

2. ETOH, opiate/benzo withdrawal

Answer

1. Patient a danger to themselves/others?
2. Evaluate in quiet area, reassure, listen
3. Good history, good physical
4. ALOC Protocol
5. EKG if tachy, chest pain; TSH
6. Treatment-rx

Answer

a. Benzo’s IV, IM, PO (3-5 days MAX)

b. Psych consult, primary care referral

c. Home, family, friends

d. Benzo Rx only for 3-5 days max if discharged

i. They are in the same category as opiates

Answer

 <3% population but common in ED

Answer

 Medication non-compliance- i thought i was doing well
 Frequent SI
 Mixed disorders, substance abuse
 Recent stressors
 Poor support/situation
 No regular psych treatment

Answer

• May need chemical restraint, treatment
• Benzo’s
• Geodon, Haldol to tx sx’s - voices, agitation

• Good history/PE - get info
• New = medical work-up
• Not new? What caused this change?
• Psych consult, follow-up

Answer

1. Common with phenothiazines, Haldol

2. Buccolingual, oculogyric, neck

Answer

Benadryl - acute IV, outpt PO

Answer

ALOC, fever, “lead pipe” rigidity, autonomic instability - rare – sick - admit

Answer

ALOC, fever, tremor/shakes, rigid LE’s, hyperreflexia

Answer

eye opening four eyes
verbal jackson 5
motor 6 cyclin

Answer

ALCOHOL

EPILEPTIC

INSULIN

OPIATES

UREMIA

Also trauma, infection, psychiatric, shock

Answer

ALCOHOL

EPILEPTIC

INSULIN

OPIATES

UREMIA

Also trauma, infection, psychiatric, shock

Question 6

6

Easily distracted, poor attention span

delirium or dementia

delirium

Question 7

7

Multiple cognitive defects: memory, language, attention, orientation, visual-spatial

Dementia

Question 8

8

visual hallucinations psych or organic?

Question 9

9

Slower onset, acute changes, exacerbations

psych

Question 10

10

mixed disorder

Question 11

11

ddx to consdier with ALOC

Question 12

12

Red Flags

Question 13

13

characteristics of delirium (8)

Question 14

14

ALOC protocol (7)

Question 15

15

observation and info

Question 16

16

history that you should get

Question 17

17

orientation questions

Question 18

18

traumatic ALOC hx

Question 19

19

HX from family and friends

Question 20

20

PE

Question 21

21

GCS score

Question 22

22

GCS categories and how many points are they worth

Question 23

23

eye opening graded on

Question 24

24

verbal

Question 25

25

motor categories

Question 26

26

APVU

Question 27

27

what is the ALOC (6)

Question 28

28

what are you looking for in urine

Question 29

29

when would you get a CK

Question 30

30

when would you get a mag phos

Question 31

31

consider these in a OD

Question 32

32

what RX levels should you get

Question 33

33

what should you order in a new . psychosis

and why would you order them

Question 34

34

Consider lactic acid if

Question 35

35

why should we consider IV hydration

Question 36

36

sedation should consist of

Question 37

37

Best benzo to give

Question 38

38

geodon

what is at and what is the dose

Question 39

39

what serial exams should be done

Question 40

40

other tests that should be consider

Question 41

41

assume ALOC is ____ until proven otherwise

medical

Question 42

42

50% of psych pts are ___yrs of age

<40 yrs

Question 43

43

EDs responsibility with 5150

need to determine if

Question 44

44

how do you determine a medical clearance

Question 45

45

Ask about/uncover suicidal ideation (SI) in all psych pt’s

Question 46

46

ABBREVIATIONS for psych episodes

Question 47

47

PE

Question 48

48

when to do a medical workup

Question 49

49

You suspect an organic, not functional etiology of this behavior change get this dx tests

Question 50

50

mechanical restraints

Question 51

51

chemical restraints

Question 52

52

benzos

Question 53

53

antipsychotics

Question 54

54

rules for restraints

Question 55

55

suicide RF

Question 56

56

treatment for SI

Question 57

57

d/c of SI pts

Question 58

58

• Most common underlying cause of suicide

Question 59

59

SIGECAPS

Question 60

60

types of depression

Question 61

61

ED role in depression

Question 62

62

mania definition

Question 63

63

considerations in a pt with mania

Question 64

64

Who Is It For?

ALOC Flashcards Preview

Emergency Medicine > ALOC > Flashcards

DDx in these pt’s is broad

i. Infectionii. Intoxicatediii. Confusediv. Agitated, violentv. Neurologicvi. Traumaticvii. Psychiatricaltered pts are brought for Diagnosis, protection, stabilization, intervention, disposition

organic issue

= medical issue

functional issue

psychiatric

Disturbed level and content of consciousnessdelirium or demetnia

DeliriumDelirium is a transient disorder characterized by impaired attention, perception, thinking, memory, and cognition.

Gradual onsetdelirium or dementia

Dementia

Easily distracted, poor attention spandelirium or dementia

delirium

Multiple cognitive defects: memory, language, attention, orientation, visual-spatial

Dementia

visual hallucinations psych or organic?

a. Visual hallucinations are usually not psychiatric

Slower onset, acute changes, exacerbations

psych

mixed disorder

= Psych plus drug abuse

ddx to consdier with ALOC

 Alcohol, withdrawal Epileptic Seizure• Post-ictal state Insulin (glucose) Opiates, other drugs  Uremia, liver failure Trauma Infection**• Especially the elderly Psychiatric Shock

Red Flags

SICK old/young/immunocompramisEdPE findings: falls, trauma rash stiff neck focal neuro evidence or hx of seizure toxidromePMHhxmeds

characteristics of delirium (8)

rapid onset disorientation memory lossflucuaing ALOCsocial immodestysxs worse a nightVISUAL HALLUCINATIONdon't forget ETOH w/d

ALOC protocol (7)

pulse oxd stickupregu tox ETOH levelbowel sounds tachy-EKGpupils temperature CAN you reverse it with NARCAN or Glucose?

observation and info

what do you see hear from EMS5150past visits to ED do they have DMC?

history that you should get

what happened?pain?sick?medical problems?fall trauma?meds?are you taking them?have you used drugs or alcohol today?ORIETNATIon ?s

orientation questions

see anything unusual?orientation?do you know where you are?do you know the date?months?year?who is the president?

traumatic ALOC hx

mechanismwhen? once or ore?did you lose consciousnesswhat did you do after it happened?how do you feel now?what hurts?HA? vomiting?can you walk?

HX from family and friends

onset fast or slow?how different from normal?happened before?PMHx? meds ? psych hx?recent illness or trauma?witnessed LOC?drus?etoh?delusions or paronia?recent emotional stress?hx of suicide attempts?anything that could help me?

PE

vitals: EMS, triage, repeatappearance, undress heat to toeget permission, explain, go slowlook for toxidrome GCS

GCS score

7-9 is significantdead people get a 3document

GCS categories and how many points are they worth

eye opening (4)verbal (5)motor (6)

eye opening graded on

spontaneous to voiceto painnone

verbal

oriented confusedinappropriateincomprehensible none

motor categories

obeys commandslocalizeswithdrawsflexesextends to pain none

APVU

awakeverbalpainunresponsive

what is the ALOC (6)

Vitalsd stickpulse oxupregurinte toxetoh

what are you looking for in urine

bloodinfectionsketones

when would you get a CK

– rhabdomyolysis (agitated, stimulants, down time)

when would you get a mag phos

ETOH involvement

consider these in a OD

Tylenol, ASA level

what RX levels should you get

seizure medsdigoxin

what should you order in a new . psychosis and why would you order them

cbc chemCKmag phos tylenol ASAmed levelsHIVTSH (myxedema) RPR neurosphililis

Consider lactic acid if

Consider lactic acid if fever, hypotension

why should we consider IV hydration

Agitated, delirium, alcohol, tox: all are not eating/caring for self

sedation should consist of

IMbenzos-versed 2-5 mg geodon 10-20mg zyprexa-voices 5mg visit these pts regularly!!!

Best benzo to give

versed 2-4mg IV

geodon what is at and what is the dose

10-20 mg can give iMfor psych pt

what serial exams should be done

i. Infection
ii. Intoxicated
iii. Confused
iv. Agitated, violent
v. Neurologic
vi. Traumatic
vii. Psychiatric

altered pts are brought for Diagnosis, protection, stabilization, intervention, disposition

Disturbed level and content of consciousness

delirium or demetnia

Delirium

Delirium is a transient disorder characterized by impaired attention, perception, thinking, memory, and cognition.

Gradual onset

delirium or dementia

Easily distracted, poor attention span

delirium or dementia

 Alcohol, withdrawal
 Epileptic Seizure
• Post-ictal state
 Insulin (glucose)
 Opiates, other drugs
 Uremia, liver failure
 Trauma
 Infection**
• Especially the elderly
 Psychiatric
 Shock

SICK
old/young/immunocompramisEd

PE findings:
falls, trauma
rash stiff neck
focal neuro

evidence or hx of seizure

toxidrome

PMHhx

meds

rapid onset
disorientation
memory loss
flucuaing ALOC
social immodesty
sxs worse a night
VISUAL HALLUCINATION
don't forget ETOH w/d

pulse ox
d stick
upreg
u tox
ETOH level
bowel sounds
tachy-EKG
pupils
temperature

CAN you reverse it with NARCAN or Glucose?

what do you see
hear from EMS
5150
past visits to ED
do they have DMC?

what happened?
pain?
sick?
medical problems?
fall trauma?
meds?
are you taking them?
have you used drugs or alcohol today?
ORIETNATIon ?s

see anything unusual?
orientation?

do you know where you are?

do you know the date?
months?
year?

who is the president?

mechanism
when? once or ore?
did you lose consciousness
what did you do after it happened?
how do you feel now?
what hurts?
HA? vomiting?
can you walk?

onset fast or slow?
how different from normal?
happened before?
PMHx? meds ? psych hx?
recent illness or trauma?
witnessed LOC?
drus?
etoh?
delusions or paronia?
recent emotional stress?
hx of suicide attempts?
anything that could help me?

vitals: EMS, triage, repeat

appearance, undress heat to toe

get permission, explain, go slow
look for toxidrome

GCS

7-9 is significant
dead people get a 3
document

eye opening (4)
verbal (5)
motor (6)

spontaneous
to voice
to pain
none

oriented
confused
inappropriate
incomprehensible
none

obeys commands
localizes
withdraws
flexes
extends to pain
none

awake
verbal
pain
unresponsive

Vitals
d stick
pulse ox
upreg
urinte tox
etoh

blood
infections
ketones

seizure meds
digoxin

what should you order in a new . psychosis

and why would you order them

cbc
chem
CK
mag phos
tylenol
ASA
med levels
HIV
TSH (myxedema)
RPR neurosphililis

IM

benzos-versed 2-5 mg

geodon 10-20mg
zyprexa-voices 5mg

visit these pts regularly!!!

geodon

what is at and what is the dose

10-20 mg can give iM
for psych pt

monitor VS and mental status changes

recognize if getting worse or better

LP= fever and ALOC
HIV and ALOC
CA and ALOC
new delirium or new psychosis

CT- traumatic ALOC
new delirium w/o cause or any new psychosis

HIV, CA+ALOC =CT

EDs responsibility with 5150

need to determine if

ED “medically clears” pt’s on 5150 hold

1. ED must determine there is no medical/organic cause

2.Psych facility is not an acute medical facility!

1. Can be discharged home
2. Need medical admission
3. Need psychiatric admission

dx has been established and pt is stable for transfer

pt is able to talk to a psychiatrist
sedated.intoxicated can't be evaluate

Practitioner to practitioner transfer by phone

inform pt and family

AH = auditory hallucination

VH = visual hallucinations; SI = suicidal ideations; HI = homicidal ideations

i. Vitals

ii. General appearance

iii. Head to toe exam – get permission

iv. Orientation questions, Mini-Mental Status if able

v. Document if pt is unable or unwilling to cooperate with exam and why

vi. May need to examine after sedation

vii. Serial exams

no previous psych
>40 -first psych issue
abnormal vital signs
impaired consciousness
recent memory loss, trauma
impaired consciousness
focal neuro finding

d stick
upreg
utox

benzos )

antipsychotics

midazolam (versed) 2-5mg IM/IV
lorazepam (ativan) 1-2mg IM/IV

ziprasidone (geodon) 10-20mg IM/IV 20 mg PO

Haloperidol(haldol) 2-5mg IM/IV
add congentin 1-2mg IM/IV

1. Male, white, unemployed, single
2. Adolescents
3. Drug and/or alcohol abuse
4. Recent life stressor
5. Physical/chronic illness
6. Hx domestic violence, sexual assault/abuse
7. Major mood disorders, 10% schizophrenic pts
8. Lethality/Rescue ratio of plan
9. Past attempt, family Hx of suicide

1. Psychiatric/Attending MD consultation obtained

2. Not suicidal now

3. Risk profile low

4. Intent, gesture for secondary gain

5.Pt has family, friends here, now

6. Pt has stable home environment

7. Can f/u with psychiatrist reliably

8. Means of lethality eliminated or regulated

 Sadness
 Insomnia/Hypersomnia
 Guilt
 Mood
 Energy
 Concentration
 Appetite, activity
 Pleasure (anhedonia)
 Suicide

Organic or Functional or Situational?

– “I can’t visit my grandkids b/c my COPD has gotten really bad”-Organic

b. ED rarely initiates medical therapy (2 week rule – takes about 2 weeks for any antidepressant to work)

Discuss therapies – drugs help, medical model

ii. Psychiatric, medical, medications, drugs

iii. Patient a danger to themselves/others?

iv. Protect patient, protect staff

often start with benzos in these cases