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Mellss yr5 em acute confusional states
- 2. • What? • Approach • Management CONTENTS
- 3. • Aka delirium, acute cognitive impairment, acute encephalopathy, acute brain failure • Transient disorder with impairment of attention and cognition ACUTE CONFUSIONAL STATE
- 4. •Disturbance in attention and awareness. •Change in cognition that is not better accounted for by a preexisting, established, or evolving dementia. •The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. •There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. DSM-5 : DELIRIUM
- 5. Complex There are four general causes: 1. Primary intracranial disease 2. Systemic diseases secondarily affecting the central nervous system 3. Exogenous toxins 4. Drug withdrawal PATHOPHYSIOLOGY
- 6. • CNS disorder : Vascular: hemorrhage, HT encephalopathy Infections: meningitis, encephalitis Nutritional deficiency: thiamine, B12 Head trauma, epilepsy, degenerative • Metabolic: hepatic/ renal failure, hypoxia, electrolyte imbalance, hypoglycemia • Endocrinal: hypo/ hyperthyroidism, adrenal crisis • pulmonary: MI, CHF, respiratory failure, shock • Toxins: OP, CO, • Substance abuse CAUSES
- 7. Psychomotor features: • Hypoalert-Hypoactive : CONFUSION • Hyperalert-Hyperactive : DELIRIUM • Mixed Disrupted sleep-wake cycles (somnolence during the day and agitation at night) Hallucination,delusions, and illusions PRESENTATION
- 8. Exclude psychiatric, give table Characteri stic Acute confusion state Delirium Dementia Acute functional psychosis Onset Acute Acute Insidious Sudden Course Fluctuating Fluctuating Stable Stable Consciousness Clouded Clouded Clear Clear Attention Globally impaired Globally impaired Globally impaired Variable Cognition Globally affected Globally affected Globally affected Selectively affected Hallucinations Visual, tactile Visual, tactile - Auditory Orientation Usually impaired Mostly impaired Often impaired May be impaired Psychomotor Reduced Increased Often normal Varies
- 10. Patients = threat Bed alarms and personal sitters Physical restraints. Chemical restraints • Haloperidol 5 to 10 mg at 20- to 30-min intervals • Lorazepam 0.5 to 2 mg
- 11. History : • Situation patient found in • Baseline cognitive function • Time course • Current medication • Screening for symptoms of organ failure / systemic infection, • History of illicit drug use, alcoholism, or toxin exposure DIAGNOSIS
- 12. • General physical examination • Signs of infection, fluid status, skin appearance • Exclusion of other psychiatric disorders associated with delirium, neurodegenerative condition EXAMINATION
- 15. • Basic screening labs • Screening for systemic infection • Serum and urine drug and toxicology • Additional laboratory tests (autoimmune, endocrinologic, metabolic, and infectious etiology) INVESTIGATION
- 16. • Treatment of the underlying factor • Do not exacerbate confusion • Avoid sedatives TREATMENT
- 17. Judith E. Tintinalli, Emergency Medicine A Comprhensive Study Guide, 6th edition, 2004 Longo, Kasper,William ,Jameson, Dunlop ,Fauci, ,Hauser,Fishman , Loscalzo, Harrison's Principles of Internal Medicine, 18th edition, 2012 Sn Chugh and Eshan Gupta, Emergency Medicine, 4th edition 2014 REFERENCES
Editor's Notes
- Confuse n coma mc disorder of cons
- 10 to 25 percent of elderly hospitalized patients have delirium at the time of admission
- (ie, reduced ability to direct, focus, sustain, and shift attention) (eg, memory deficit, disorientation, language disturbance, perceptual disturbance
- involve widespread neuronal or neurotransmitter dysfunction
- Difficulty maintaining attention and focusing concentration Fall along spectrum or fluctuate Important to identify patient as potentially reversible, long-term cognitive effects of delirium remain largely unknown and understudied Eg.The cognitive syndrome associated with severe alcohol withdrawal remains the classic example of the hyperactive subtype, featuring prominent hallucinations, agitation, and hyperarousal, often accompanied by life-threatening autonomic instability. Eg.In striking contrast is the hypoactive subtype, exemplified by opiate intoxication, in which patients are withdrawn and quiet, with prominent apathy and psychomotor slowing
- to their own safety or to the safety of staff members, PO, IM, or IV1 to 2 mg in the elderly
- The history from caregivers, spouse, or other family :primary method for diagnosing delirium.-acute onset , fluctuating severity through the day and worsening at night (correlate the onset of the illness with potentially treatable etiologies such as recent medication changes or symptoms of systemic infection) ( OTC, herbal, dosing change)
- such as fever, tachypnea, pulmonary consolidation, heart murmur, and stiff neck. Skin apperance can be helpful, showing jaundice in hepatic encephalopathy, cyanosis in hypoxemia, or needle tracks in patients using intravenous drugs. screened for additional signs of neurodegenerative conditions such as parkinsonism, The presence of multifocal myoclonus or asterixis on the motor examination is nonspecific but usually indicates a metabolic or toxic etiology of the delirium.
- patients, correlates well with the MMSE, and takes less time to administer
- No established algorithm for workup will fit all delirious patients due to the staggering number of potential etiologies including a complete blood count, electrolyte panel, and tests of liver and renal function, including chest radiography, urinalysis and culture, and possibly blood cultures reserved for patients in whom the diagnosis remains unclear after initial testing Cranial CT should be done followed by lumbar puncture if meningitis or subarachnoid
- Lit room, limit staff, relative