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ACUTE CONFUSIONA

L STATES

• What?• Approach • Management

CONTENTS

• Aka delirium, acute cognitive impairment, acute encephalopathy, acute brain failure

• Transient disorder with impairment of attention and cognition

ACUTE CONFUSIONAL STATE

•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

Complex There are four general causes:

1. Primary intracranial disease2. Systemic diseases secondarily affecting the central nervous system3. Exogenous toxins4. Drug withdrawal

PATHOPHYSIOLOGY

• 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

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

Exclude psychiatric, give table

Characteristic

Acute confusion state

Delirium Dementia

Acute functional psychosis

Onset Acute Acute Insidious SuddenCourse 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

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

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

• General physical examination

• Signs of infection, fluid status, skin appearance

• Exclusion of other psychiatric disorders associated with delirium, neurodegenerative condition

EXAMINATION

• Basic screening labs• Screening for systemic

infection• Serum and urine drug and

toxicology• Additional laboratory tests

(autoimmune, endocrinologic, metabolic, and infectious etiology)

INVESTIGATION

• Treatment of the underlying factor• Do not exacerbate confusion• Avoid sedatives

TREATMENT

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