Heads up
These two time-critical intracranial causes make up the "S" in AEIOU-TIPS.
What are stroke and seizure?
This bedside test should be done within minutes for every AMS patient, before any imaging.
What is a fingerstick glucose?
Patient presents to the ED via EMS after being found down by his roommate. RR 6. On exam, he has pinpoint pupils and does not answer questions or follow commands, but he does withdraw to pain.
What is the next step to treat his respiratory depression?
What is naloxone (Narcan)?
Diagnosis: opioid overdose
This syndrome is defined as acute, fluctuating inattention.
What is delirium?
The most common cause of altered mental status in a large ED cohort (about 29% of cases)
What is systemic infection/sepsis?
A unilateral fixed, dilated pupil in a comatose patient suggests compression of this cranial nerve.
What is CN III (uncal herniation)?
AKA Oculomotor nerve
A 68-year old female presents to the ED with confusion and wobbly gait. On chart review, you notice a recent BMI of 16 as well as extensive alcohol intake reported by PCP at a visit last week.
What is the treatment for their condition?
What is IV thiamine (B1)?
Diagnosis: Wernicke encephalopathy
An 84-year old M is brought into the ED by his wife. She tells you he is confused and he keeps holding his ears, saying "stop that ringing!". He is febrile, otherwise VSS. Labs: Anion gap 21, pH 7.48, PCO2 29.
What is your suspected diagnosis?
What is salicylate toxicity?
An 84-year-old with Alzheimer's becomes acutely confused during a hospitalization. The family says, "This is not how she normally acts."
What is the term for her condition?
What is delirium superimposed on dementia?
An 82 yo male is brought to the ED with acute onset delirium and agitation. He was recently seen by Dr. Human, who started him on Benadryl for pruritis. He has no focal neuro deficits on exam. He slaps your hand away when you try to palpate his lower abdomen. What would your initial imaging of choice be?
What is a bladder ultrasound?
Patient presents to the ED after a seizure. They remain confused well past the expected post-ictal window. On exam, you observe subtle eye twitching.
What is the diagnostic test for the condition you are suspicious for?
What is an EEG?
Diagnosis: nonconvulsive status epilepticus aka NCSE
A ____ level above 14 mg/dL is generally considered severe and can cause lethargy, confusion, and coma.
What is calcium?
Hypercalcemia - stones, bones, groans, psych overtones
A patient presents to the ED with an ataxic gait, slurred speech, confusion, and a tremor. He has Bipolar disorder which has been stable over the past decade on lithium. He was recently diagnosed with hypertension and started on HCTZ and lisinopril.
What is your suspected diagnosis?
What is lithium toxicity?
This one's for you, Evelyn!
You are paged to see an EPFM patient in the ED for AMS. He is alert but not responding to your questions. You notice a continued blank stare. You also notice that he holds his arm up in the same position you place it.
Hint: A lorazepam challenge is both diagnostic and therapeutic. What is the most likely diagnosis?
What is catatonia?
A patient w/ T2DM and CKD4 presents to the ED with confusion and lethargy. Exam: A&Ox1, somnolent but arousable, brief arrhythmic lapses of posture when dorsiflexing wrists bilaterally. Labs show BUN 147 and Cr 12. Based on your suspected diagnosis, who do you plan on consulting emergently?
What is nephrology?
Diagnosis: uremic encephalopathy
An 81-year-old w/ Afib on apixaban presents to ED w/ progressive confusion and three falls at home over the last month. Family recalls a minor "bump" to the head about two months ago. On exam, you notice downward drift of his right arm. Initial labs are normal. What will you order next based on your suspected diagnosis?
What is a noncon head CT?
Diagnosis: chronic subdural hematoma
A 55-year old male presents with hypothermia, bradycardia, hyponatremia, and altered mental status.
His wife reports he stopped taking levothyroxine last month.
What is the initial treatment(s) for his condition?
What is IV levothyroxine?
A patient w/ recently diagnosed latent Tb on Isoniazid is brought into the ED for persistent seizures, without improvement despite lorazepam x2. Lab shows an anion gap acidosis.
What is the main treatment for his condition?
What is IV pyridoxine (Vitamin B6)?
Diagnosis: Isoniazid toxicity
About 48-96 hours after their last drink, patient presents with tremor, hallucinations, and delirium. What is the first line medication to treat this syndrome?
What are benzodiazepines? (ex IV lorazepam or diazepam)
One of the "T" causes in AEIOU-TIPS that include a pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia, renal injury, and neurologic changes.
What is thrombotic thrombocytopenic purpura (TTP)?
A graduate student with a recent "flu" is brought in by her roommate who says, "she thinks I'm trying to poison her and she keeps hearing things that aren't there". She is admitted to psych. The next day, she is smacking her lips and not speaking. HR is 50-140, and she begins seizing. You do some more chart review and see a "dermoid cyst" on a pelvic US last year. Diagnosis?
What is anti-NMDA receptor encephalitis?
A 68-year old male presents to ED via EMS for confusion. VS notable for BP 99/52. You immediately begin fluid resuscitation. Labs show: glucose 58, Na 130, K 5.6. After 2 L fluid bolus, BP is 100/55.
Pertinent medical hx: longstanding RA, recently stopped prednisone
What specific lab would you like to add on STAT?
What is cortisol (bonus for ACTH, aldosterone, renin)?
Dx: adrenal crisis
Two children are brought into MBED via EMS after being found lying on the floor by their neighbor, who was taking care of them while their parents were out of town. The neighbor states upon waking the kids, they were acting confused and "not like themselves".
All VS are unremarkable. On exam, the two children are holding emesis bags. They are both A&Ox1. You notice they both have bright pink skin diffusely.
What is the mainstay of treatment?
What is 100% O2?
Diagnosis: Carbon monoxide poisoning
A 76-year old is brought into the ED for gradual worsening of visual hallucinations, cognitive deficits, and bilateral tremor over several months. She received Haldol for noted agitation. You start your shift the next morning and notice she is obtunded and extremely stiff on exam, with a fever of 104 F. What is the single most important treatment for her condition?
What is stop the offending agent?
Diagnosis: Neuroleptic malignant syndrome (NMS)
This antibiotic class is listed as most likely to cause delirium.
What are beta-lactams (ex. cefepime neurotoxicity, especially with renal impairment)?