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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
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