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Emergency Medicine > ALOC > Flashcards

ALOC Flashcards

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1
Q

DDx in these pt’s is broad

A

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

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2
Q

organic issue

A

= medical issue

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3
Q

functional issue

A

psychiatric

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4
Q

Disturbed level and content of consciousness

delirium or demetnia

A

Delirium

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

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5
Q

Gradual onset

delirium or dementia

A

Dementia

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6
Q

Easily distracted, poor attention span

delirium or dementia

A

delirium

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7
Q

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

A

Dementia

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8
Q

visual hallucinations psych or organic?

A

a. Visual hallucinations are usually not psychiatric

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9
Q

Slower onset, acute changes, exacerbations

A

psych

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10
Q

mixed disorder

A

= Psych plus drug abuse

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11
Q

ddx to consdier with ALOC

A 
	Alcohol, withdrawal
	Epileptic Seizure
•	Post-ictal state
	Insulin (glucose)
	Opiates, other drugs	
	Uremia, liver failure
	Trauma
	Infection**
•	Especially the elderly
	Psychiatric
	Shock
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12
Q

Red Flags

A

SICK
old/young/immunocompramisEd

PE findings:
falls, trauma
rash stiff neck
focal neuro

evidence or hx of seizure

toxidrome

PMHhx

meds

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13
Q

characteristics of delirium (8)

A 
rapid onset 
disorientation 
memory loss
flucuaing ALOC
social immodesty
sxs worse a night
VISUAL HALLUCINATION
don't forget ETOH w/d
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14
Q

ALOC protocol (7)

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

CAN you reverse it with NARCAN or Glucose?

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15
Q

observation and info

A 
what do you see 
hear from EMS
5150
past visits to ED 
do they have DMC?
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16
Q

history that you should get

A 
what happened?
pain?
sick?
medical problems?
fall trauma?
meds?
are you taking them?
have you used drugs or alcohol today?
ORIETNATIon ?s
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17
Q

orientation questions

A

see anything unusual?
orientation?

do you know where you are?

do you know the date?
months?
year?

who is the president?

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18
Q

traumatic ALOC hx

A 
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?
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19
Q

HX from family and friends

A 
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?
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20
Q

PE

A

vitals: EMS, triage, repeat

appearance, undress heat to toe

get permission, explain, go slow
look for toxidrome

GCS

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21
Q

GCS score

A

7-9 is significant
dead people get a 3
document

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22
Q

GCS categories and how many points are they worth

A

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

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23
Q

eye opening graded on

A

spontaneous
to voice
to pain
none

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24
Q

verbal

A 
oriented 
confused
inappropriate
incomprehensible 
none
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25
motor categories
``` obeys commands localizes withdraws flexes extends to pain none ```
26
APVU
awake verbal pain unresponsive
27
what is the ALOC (6)
``` Vitals d stick pulse ox upreg urinte tox etoh ```
28
what are you looking for in urine
blood infections ketones
29
when would you get a CK
– rhabdomyolysis (agitated, stimulants, down time)
30
when would you get a mag phos
ETOH involvement
31
consider these in a OD
Tylenol, ASA level
32
what RX levels should you get
seizure meds | digoxin
33
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 ```
34
Consider lactic acid if
Consider lactic acid if fever, hypotension
35
why should we consider IV hydration
Agitated, delirium, alcohol, tox: all are not eating/caring for self
36
sedation should consist of
IM benzos-versed 2-5 mg geodon 10-20mg zyprexa-voices 5mg visit these pts regularly!!!
37
Best benzo to give
versed 2-4mg IV
38
geodon what is at and what is the dose
10-20 mg can give iM | for psych pt
39
what serial exams should be done
monitor VS and mental status changes recognize if getting worse or better
40
other tests that should be consider
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
41
assume ALOC is ____ until proven otherwise
medical
42
50% of psych pts are ___yrs of age
<40 yrs
43
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
44
how do you determine a medical clearance
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
45
Ask about/uncover suicidal ideation (SI) in all psych pt’s
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?
46
ABBREVIATIONS for psych episodes
AH = auditory hallucination VH = visual hallucinations; SI = suicidal ideations; HI = homicidal ideations
47
PE
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
48
when to do a medical workup
``` no previous psych >40 -first psych issue abnormal vital signs impaired consciousness recent memory loss, trauma impaired consciousness focal neuro finding ```
49
You suspect an organic, not functional etiology of this behavior change get this dx tests
d stick upreg utox
50
mechanical restraints
Soft restraints, leathers, belts, mask
51
chemical restraints
benzos ) antipsychotics
52
benzos
midazolam (versed) 2-5mg IM/IV | lorazepam (ativan) 1-2mg IM/IV
53
antipsychotics
ziprasidone (geodon) 10-20mg IM/IV 20 mg PO Haloperidol(haldol) 2-5mg IM/IV add congentin 1-2mg IM/IV
54
rules for restraints
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
55
suicide RF
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
56
treatment for SI
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!
57
d/c of SI pts
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
58
• Most common underlying cause of suicide
DEPRESSION
59
SIGECAPS
```  Sadness  Insomnia/Hypersomnia  Guilt  Mood  Energy  Concentration  Appetite, activity  Pleasure (anhedonia)  Suicide ```
60
types of depression
Organic or Functional or Situational? – “I can’t visit my grandkids b/c my COPD has gotten really bad”-Organic
61
ED role in depression
b. ED rarely initiates medical therapy (2 week rule – takes about 2 weeks for any antidepressant to work) Discuss therapies – drugs help, medical model
62
mania definition
“Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week”
63
considerations in a pt with mania
ii. Psychiatric, medical, medications, drugs iii. Patient a danger to themselves/others? iv. Protect patient, protect staff often start with benzos in these cases
64
workup and tx of pt with mania
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
65
Formication
feel that they are infested with bugs or some sort of unusual virus; meth disease
66
common dx sources of secondary anxiety
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"
67
rxs you want to think about in a pt with anxiety
1. Sympathomimetics, caffeine, herbals, cannabis, LSD, ecstasy, benzo’s w/d! 2. ETOH, opiate/benzo withdrawal
68
vii. Anxiety Evaluation/Tx
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
69
RX anxiety
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
70
how often do you see schizophrenia
 <3% population but common in ED
71
story of schizophrenia in the ED
```  Medication non-compliance- i thought i was doing well  Frequent SI  Mixed disorders, substance abuse  Recent stressors  Poor support/situation  No regular psych treatment ```
72
workup and tx od schizophrenia in the ED
* 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
73
Dystonic Reaction
1. Common with phenothiazines, Haldol | 2. Buccolingual, oculogyric, neck
74
Dystonic Reaction tx
Benadryl - acute IV, outpt PO
75
Neuroleptic Malignant Syndrome
ALOC, fever, “lead pipe” rigidity, autonomic instability - rare – sick - admit
76
Serotonin Syndrome | sxs
ALOC, fever, tremor/shakes, rigid LE’s, hyperreflexia
77
GCS
eye opening four eyes verbal jackson 5 motor 6 cyclin
78
AEIOU
ALCOHOL EPILEPTIC INSULIN OPIATES UREMIA Also trauma, infection, psychiatric, shock
79
AEIOU
ALCOHOL EPILEPTIC INSULIN OPIATES UREMIA Also trauma, infection, psychiatric, shock

Emergency Medicine (28 decks)

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