Flashcards in ALOC Deck (79):
DDx in these pt’s is broad
iv. Agitated, violent
altered pts are brought for Diagnosis, protection, stabilization, intervention, disposition
= medical issue
Disturbed level and content of consciousness
delirium or demetnia
Delirium is a transient disorder characterized by impaired attention, perception, thinking, memory, and cognition.
delirium or dementia
Easily distracted, poor attention span
delirium or dementia
Multiple cognitive defects: memory, language, attention, orientation, visual-spatial
visual hallucinations psych or organic?
a. Visual hallucinations are usually not psychiatric
Slower onset, acute changes, exacerbations
= Psych plus drug abuse
ddx to consdier with ALOC
• Post-ictal state
Opiates, other drugs
Uremia, liver failure
• Especially the elderly
rash stiff neck
evidence or hx of seizure
characteristics of delirium (8)
sxs worse a night
don't forget ETOH w/d
ALOC protocol (7)
CAN you reverse it with NARCAN or Glucose?
observation and info
what do you see
hear from EMS
past visits to ED
do they have DMC?
history that you should get
are you taking them?
have you used drugs or alcohol today?
see anything unusual?
do you know where you are?
do you know the date?
who is the president?
traumatic ALOC hx
when? once or ore?
did you lose consciousness
what did you do after it happened?
how do you feel now?
can you walk?
HX from family and friends
onset fast or slow?
how different from normal?
PMHx? meds ? psych hx?
recent illness or trauma?
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
7-9 is significant
dead people get a 3
GCS categories and how many points are they worth
eye opening (4)
eye opening graded on
extends to pain
what is the ALOC (6)
what are you looking for in urine
when would you get a CK
– rhabdomyolysis (agitated, stimulants, down time)
when would you get a mag phos
consider these in a OD
Tylenol, ASA level
what RX levels should you get
what should you order in a new . psychosis
and why would you order them
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
benzos-versed 2-5 mg
visit these pts regularly!!!
Best benzo to give
versed 2-4mg IV
what is at and what is the dose
10-20 mg can give iM
for psych pt
what serial exams should be done
monitor VS and mental status changes
recognize if getting worse or better
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
assume ALOC is ____ until proven otherwise
50% of psych pts are ___yrs of age
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
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
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?
ABBREVIATIONS for psych episodes
AH = auditory hallucination
VH = visual hallucinations; SI = suicidal ideations; HI = homicidal ideations
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
when to do a medical workup
no previous psych
>40 -first psych issue
abnormal vital signs
recent memory loss, trauma
focal neuro finding
You suspect an organic, not functional etiology of this behavior change get this dx tests
Soft restraints, leathers, belts, mask
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
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
1. Male, white, unemployed, single
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
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!
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
• Most common underlying cause of suicide
types of depression
Organic or Functional or Situational?
– “I can’t visit my grandkids b/c my COPD has gotten really bad”-Organic
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
“Distinct period of abnormality, persistently elevated, expansive or irritable mood, lasting at least a week”
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
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
feel that they are infested with bugs or some sort of unusual virus; meth disease
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
"i'm not finding a medical problem tonight"
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
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
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
how often do you see schizophrenia
<3% population but common in ED
story of schizophrenia in the ED
Medication non-compliance- i thought i was doing well
Mixed disorders, substance abuse
No regular psych treatment
workup and tx od schizophrenia in the ED
• May need chemical restraint, treatment
• 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
1. Common with phenothiazines, Haldol
2. Buccolingual, oculogyric, neck
Dystonic Reaction tx
Benadryl - acute IV, outpt PO
Neuroleptic Malignant Syndrome
ALOC, fever, “lead pipe” rigidity, autonomic instability - rare – sick - admit
ALOC, fever, tremor/shakes, rigid LE’s, hyperreflexia
eye opening four eyes
verbal jackson 5
motor 6 cyclin
Also trauma, infection, psychiatric, shock