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Flashcards in ALOC Deck (79)
1

DDx in these pt’s is broad

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

2

organic issue

= medical issue

3

functional issue

psychiatric

4

Disturbed level and content of consciousness

delirium or demetnia

Delirium

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

5

Gradual onset

delirium or dementia

Dementia

6

Easily distracted, poor attention span

delirium or dementia

delirium

7

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

Dementia

8

visual hallucinations psych or organic?

a. Visual hallucinations are usually not psychiatric

9

Slower onset, acute changes, exacerbations

psych

10

mixed disorder

= Psych plus drug abuse

11

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

12

Red Flags

SICK
old/young/immunocompramisEd

PE findings:
falls, trauma
rash stiff neck
focal neuro

evidence or hx of seizure

toxidrome

PMHhx

meds

13

characteristics of delirium (8)

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

14

ALOC protocol (7)

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

CAN you reverse it with NARCAN or Glucose?

15

observation and info

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

16

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

17

orientation questions

see anything unusual?
orientation?

do you know where you are?

do you know the date?
months?
year?

who is the president?

18

traumatic ALOC hx

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?

19

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?

20

PE

vitals: EMS, triage, repeat

appearance, undress heat to toe

get permission, explain, go slow
look for toxidrome

GCS

21

GCS score

7-9 is significant
dead people get a 3
document

22

GCS categories and how many points are they worth

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

23

eye opening graded on

spontaneous
to voice
to pain
none

24

verbal

oriented
confused
inappropriate
incomprehensible
none

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