Altered Mental Status

Altered Mental Status
A.      Alcohol
E.       Endocrine(thyroid), Electrolyte(Na,Ca), Epilepsy, Encephalopathy
I.        Insulin ( hyper-/hypoGlycemia)
O.       Oxygen, Opioid
U.       Uremia
T.       Trauma, Temperature
I.        Infection (CNS, Systemic)
P.       Poison, Psychosis
S.       Shock(HypoVolemic, AMI), Stroke/SAH/Structural lesion


Hx: 什麼候開始, 怎麼不一樣(baseline如何), Seizure/Epilepsy, Headache/ head injury, Drug (new drugs)
PE: TPR, BP, SpO2, Auscultation, Tongue-biting, Head trauma, Odor(EtOH, Ketone)
NE: Pupil(pinpoint/dilate, deviation), GCS, Babinski
Lab: FingerSugar, BUN/Cr, Na/Ca, LFTs/NH3, CBC-DC/PLT, PT/aPTT, BloodCulture, UA/U.culture, Toxic Screen, Alcohol, BZD, TFTs, Troponin
Exam: EKG, CXR, (Brain + C-spine) CT, Lumbar puncture

[AITFL] Manage of Syncope

The most common causes of syncope are: Unknown (34-36%), Vasovagal (18-21%), and Cardiac (9.5-18%). Soteriades et al noted that if patients have a history of CV disease, the incidence of cardiac etiology also increases.

Causes of Syncope & The Presence or Absence of CV Disease
CV Disease	CV Disease Absent		CV Disease Present
Sex	Male	Female	Male	Female
Cardiac Etiology	6.5%	3.8%	26.7%	16.8%

San Francisco Syncope Rule

The mnemonic for features of the rule is CHESS:

• C - History of congestive heart failure

• H - Hematocrit < 30%

• E - Abnormal ECG

• S - Shortness of breath

• S - Triage systolic blood pressure < 90

What is the ACEP Level-B Recommendation for Admission?

• Older age and associated comorbidities (No set definition) 
• Abnormal EKG findings (acute ischemia, dysrhythmias, or significant conduction abnormalities) 
• Hematocrit <30 
• History or presence of CHF, CAD, or structural heart disease 

Does Everyone with Syncope Need a Head CT?

Bottom Line: Clinicians might consider obtaining a Head CT as part of the syncope evaluation for the following findings:

• Trauma above the clavicle 
• Persistent neurologic deficit or complaint 
• Age >65 
• Sudden onset headache 
• Patients on warfarin (coumadin)

Trauma Rules (V6 網誌分享)

Rule 1: 如有頻脈或皮膚血管收縮現象，則先當休克直到証明不是為止。
Rule 2: 外傷 + 休克，則先當出血性休克直到証明不是為止。
Rule 3: 先找外出血再找內出血;沒有出血就找非出血。

Internal bleeding (CRAMP)
Chest                              ->CXR
Retroperitoneum          ->UA/CT
Abdomen                       ->FAST
Missed long bone fx    ->PE
Pelvic-                            ->pelvic XR

Non-bleeding     (NPC)
Neurogenic shock
Pneumothorax,tension
Cardiac tamponade/cardiac contusion

<自行整理>
1. Ultrasound (E-FAST)可以cover Chest, Abdomen, PTX & Cardiac tamponade/contusion
2. CT可以cover Retropenium, Neurogenic shock
3. PE rule out long bone fracture

[自行整理]Distal Clavicular Fracture

Neer classification of distal clavicle fractures. 
Type I fracture occurs distal to the coracoclavicular (CC) ligaments (ie, trapezoid, conoid) and involves minimal fracture displacement. The acromioclavicular (AC) joint remains intact. 
Type IIA fracture occurs medial to the conoid ligament. Type IIB fracture occurs between the CC ligaments and includes disruption of the conoid ligament. The trapezoid ligament remains intact. 
Type III fracture occurs distal to the CC ligaments and extends into the AC joint. 
Type IV fracture occurs in pediatric patients. The physis and epiphysis remain adjacent to the AC joint, but there is displacement at the junction of the metaphysis and physis. 
In type V fracture, a small inferior clavicular fragment remains attached to the CC ligaments.
只有Type II & V需要early orthopedic consultation due to unstable (Minor Emergencies 2e, P434)

[自行整理] Chap. 50: Splinting Techniques [Clinical Procedures in Emergency Medicine]

Caveats for Proper Emergency Department Splinting

1. Smooth and mold the splint without squeezing. Use the palms, not the fingers to mold the splint to fit the contour of the body part.

2. Simply roll elastic bandages over an extremity without undue tension.

3. Post-check includes function, arterial pulse, capillary refills, temperature of skin, and sensation (FACTS).

4. Tape over metal clips used to fasten the elastic bandages to keep in place and avoid ingestion by child.

Padding

1. The stockinete should extend at least 10~15 cm beyond the area to be splinted at both ends of the extremities. It can be folded back over the ends of the splint to create smooth, padded rims

2. Wrinkling over flexion creases should also be avoided by slitting and overlapping the stockinette at bony prominences.

3. Padding should be at least 2~3 layers thick and each turn should overlap the previous turn by 25~50% of its width. If significant swelling is anticipated, 3 or 4 layers of padding should be added. It should also extend 2.5~5 cm beyond the ends of the splint so that it, too, can be folded back over areas of bony prominence.

4. Care should be taken to avoid wrinkling, because significant skin pressure might occur.

5. Rare complication of circumferential padding is ischemic injury due to unanticipated swelling. This can be prevented by cutting throught the padding along the side of the extremitiy opposite to the plaster splint.

6. Areas that Require Additional Padding

a. Upper extremities: Olecranon, Radial styloid, Ulnar styloid

b. Lower extremities: Upper portion of inner thigh, Patella, Fibular head, Achilles tendon, Medial & lateral malleoli

Plaster Preparation

1. For an average-sized adult, upper extermities should be splinted with 8 sheets of plaster, whereas lower extremities injuries generally requires 12~15 sheets.

Splint Application

1. Molding the wet splint to conform to the body's anatomy is probably the most important, yet the most frequently overlooked step to ensure adequate immobilization. 

2. A single layer of padding or roll gauze can be wrapped around the wet plaster loosely before application of the elastic bandage, to prevent incorporation of elastic bandage into the drying plaster. Only one layer of padding should be use to prevent high drying temperature.

3. Most patients feel better immediately after the splint has been applied. Never release a patient who complains of increased pain after splinting

Patient instructions

1. Cold packs should be applied for at least 30 mins at a time, which is in contrast to the popular recommendation of "ice 20 minutes on, 20 minutes off" which does nothing more than cool the skin.

2. Cold packs should not be applied for more than the first 24~48 hours because cold can interfere with long term healing.

[自行整理] Immobilization Devices and Uses

Table 264-3 Immobilization Devices and Uses

Immobilization Technique Clinical Application Shoulder immobilizer Clavicle fracture. Acromioclavicular separation. Shoulder dislocation (postreduction). Humeral neck fracture. Sling A variety of upper extremity injuries, in conjunction with other immobilization techniques; may be used alone for nondisplaced or clinically suspected fracture of the radial head. Long-arm gutter Elbow fracture other than nondisplaced radial head fracture. Reduced elbow dislocation  Sugar-tong (可prevent pronation/supination) Wrist or forearm fracture. Distal radial and ulna (Robert & Hedges) Short-arm gutter Metacarpal or proximal phalanx fracture. [Ulnar gutter for fourth or fifth ray] [Radial gutter for second (index) or third (middle) ray.] 若是metacarpal neck fracture, 則把MCP固定在90度 (Robert & Hedges) Thumb spica 固定時維持opposition (OK sign) Scaphoid fracture (proven or suspected). Thumb metacarpal or proximal thumb phalanx fracture Knee immobilizer Fracture or reduced subluxation of patella. Knee dislocation, postreduction (temporary). Tibial plateau fracture. Knee ligament injury. Suspected meniscal tear (provided the knee can be fully extended). Posterior ankle mold (consider above-the-knee extension and/or adjunctive use of ankle sugar-tong for unstable ankle injuries) Ankle dislocation or fracture-dislocation. Unstable ankle fracture (high distal fibular fracture or medial and/or posterior malleolar fracture). Widened medial mortise (indicates disruption of stabilizing medial structures). Metatarsal fracture (alternative immobilization dressings may be used). Ankle stirrup Simple ankle sprain Stable lateral malleolus fracture (below the superior border of the talus) without other ankle involvement (no medial swelling or tenderness, posterior malleolus intact). Hard-soled shoe Toe fracture. Some metatarsal fractures Short-leg walking boot Some toe or foot contusions or fractures where weightbearing is allowed

EMCrit Podcast 20 – The Crashing Atrial Fibrillation Patient by EMCRIT on FEBRUARY 12, 2010

Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation… What are you going to do???

Yeah, yeah the Pavlovian ACLS response–You cardiovert. Wonderful, except it didn’t change a thing. Now what?

In this episode, I discuss the crashing atrial fibrillation patient.

Shock

If the patient is chronically in atrial fib, the shock rarely works. Your patient is unstable, so you decide to give it a shot. You might as well give yourself the best chance of success, so go right for 360 J on monophasic, or equivalently high on your biphasic. This will not cause more injury than lower joules (Heart 1998, 80:3 and Resuscitation 1998;36:193). PA is probably better than AA if you have pads. Make sure the synch is on.

You need to give your patient something to disguise the fact that you are electrocuting them. Yet you don’t want to drop their pressure. Ketamine is ok in disassociative dosing, but then your patient is loopy and you lose your mental status exam. Consider 5-7 mg of etomidate along with a pain dose of ketamine, 10-15 mg.

Screen for WPW

If you have a. fib with a wide QRS and a rate > 250-300, be scared, very scared. This is WPW and these patients just love to ruin your day by going into v. fib. Shock early, shock often, light them up.

Get the BP Up

So you made sure it’s not WPW and the cardioversion has failed, as it so often does in chronic a. fib. Now you need to raise the BP before anything else. Use push-dose phenylephrine. 50-200 mcg every minute or so until you get the blood pressure above a diastolic of 60; this will temporize the situation and make the patient’s heart more likely to slow down.

Though things look better, you have not really fixed the problem, you have just temporized.

Slow them them down

Give either amiodarone 150 mg bolus and then the drip (may repeat the bolus x 1)

Or

Use diltiazem, but not as a push. Drip it in at 2.5 mg/minute until HR < 100 or you get to 50 mg. See here for more.

Still not working?

• Consider magnesium
• Consider reshocking
• Consider cardiology consult
• Consider something else is going on

EMCrit Podcast 39 – Hyponatremia by EMCRIT on JANUARY 17, 2011

When they are <130 is when I get a little worried
Step I-Send Lots of Labs

Here is what you need:

Serum-electrolytes, osmolality, uric acid (if on diuretics), and you might as well send a TSH and cortisol as well (if you have any suspicion of an endocrine cause)

Urine-UA, urine lytes, urine urea, urine uric acid (if on diuretics), urine osm, urine creatinine

Want to learn more about FENa and FEUrea? Well I have an article for you.

Step II-Treat CNS dysfunction

If the patient is altered, comatose, seizing, or has neurologic findings, then raise the sodium by a little bit

Give 3% saline, 100 ml over 10-60 minutes (2 cc/kg up to a max of 100 cc)

10 minutes later, may repeat X 1

may be given peripherally through any reasonable IV

each 100 ml will raise sodium by ~2 mmol/l

Rules Of 3: 3 ml/kg of 3% saline over 30 mins ( should raise by 4 mmol)

Step III-Hang tight

Do not feel the need to do anything else, just fluid restrict the patient

Place a foley

Do not feel tempted to give NS

Do not be clever, just fluid restrict and admit.

Patients are at a fall risk with hyponatremia

Get a CT scan if they are still a little wacky

Remember the rules of 6’s (from the Stern article below)

Be incredibly careful when correcting hypokalemia, potassium repletion will raise the Na

Step IV-What to do when you couldn’t follow step III

dDAVP 1-2 mcg IV or SubQ x 1

Consult renal

Consider D5W 6ml/kg over 1 hour in consultation with renal if you have really screwed up

[自行整理] C-Spine CT Rules (NEXUS, CCR)

NEXUS Criteria (National Emergency X-radiography Utilization Study Low-Risk Criteria)       NEJM2000;343:94 –99

A patient’s neck can be clinically cleared safely without radiographic imaging if ALL 5 low-risk conditions are NEGATIVE:                            (mnemonic: NSAID)

1. Focal Neurological deficit

2. Spinal (posterior midline) tenderness

3. Altered mental status

4. Intoxication 

5. Clinically apparent, painful Distracting injury

Canadian C-spine Rules (CCR)                                                                       NEJM2003;349:2510 –2518

The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.                                                                                         N Engl J Med. 2003 Dec 25;349(26):2510-8.

CCR was more sensitive than the NLC (99.4 % vs. 90.7 %, P<0.001) and more specific (45.1 % vs. 36.8 %, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 % vs. 66.6 %, P<0.001).

In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 % and 40.4 %, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 % (P=0.09 for the comparison with the NLC) and 50.7 % (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries.

Conclusion: For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury

[EKG] Brugada Syndrome

Brugada syndrome has 3 different ECG patterns:

• Type 1 has a coved type ST elevation with at least 2 mm (0.2 mV) J-point elevation a gradually descending ST segment followed by a negative T-wave.
• Type 2 has a saddle back pattern with a least 2 mm J-point elevation and at least 1 mm ST elevation with a positive or biphasic T-wave. Type 2 pattern can occasionally be seen in healthy subjects.
• Type 3 has either a coved (type 1 like) or a saddle back (type 2 like) pattern with less than 2 mm J-point elevation and less than 1 mm ST elevation. Type 3 pattern is not uncommon in healthy subjects.
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