This document defines and describes acute confusional state (also known as delirium). It notes that delirium is a transient disorder involving impaired attention and cognition, caused by a medical condition, substance use, or medications. The document outlines the pathophysiology, causes, presentation, diagnosis, treatment, and management of delirium. It compares delirium to other conditions like dementia and acute functional psychosis.

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