Altered mental status (AMS)

• Change in level of consciousness (LOC)
• Confusion
• Delirium (acute)
• Dementia (chronic)
• Psychosis

Differential diagnosis

• See work-up to help narrow it down...

• Seek collateral history for rx/ingestion/drug history (med list, pill bottles, pharmacy#, etc.)
• Focused history
• c/o fever, neck stiffness?
• Sx ↑ intracranial pressure (ICP)? (HA, n/v, visual/neuro sx)
• Seizure?
• Recent trauma? anticoagulated?
• Last drink?
• PMH
• Focused neuro exam

Level of consciousness

• Responsive to voice? to physical stimulus? (shake, hand threat near eyes, nailbred pressure, sternal rub)
• Descriptions (RASS, GCS)
• Hyperactive, hyperalert, vigilant, agitated
• Normal
• Somnolent, lethargic (sleepy but awake/easily arousable)
• Obtunded (sleepy; slowed psychomotor responses)
• Stuporous (sleep-like; briefly arousable w/ physical stimulation)
• Comatose (unresponsive, unarousable to physical stim)

• Fingerstick glucose
• ABG (hypercapnic? hypoxic?)
• Others as indicated
• CBC, coags, type+screen (anticoagulated/trauma/bleed?)
• BMP/CMP (electrolyte abnormalities?)
• UDS +/- therapeutic drug levels (tox?)
• UA/UCx, CXR, BCx, other fluid cx (infection?)
• Ammonia, TSH (metabolic abnormalities?)
• Imaging (pt must have stable VS/airway to go to radiology)
• CXR (infection/pneumonia?)
• C-spine X-ray (trauma)
• Head CT noncon (stroke/hemorrhage/herniation/focal lesion?)
• If no CT correlate for focal neuro findings, consider brain MR later
• LP
• Do head CT first
• r/o CNS infection (or start empiric abx: vanc + ceftriaxone +/- amp +/- acyclovir
• r/o subarachnoid hemorrhage if high clinical suspicion and negative CT (CT only 90% sens)
• EEG
• Nonconvulsive status epilepticus
• Diffuse slowing can be: delirium, HSV encephalitis, metabolic encephalopathy

Empiric therapy

• ABC...D (drugs)
• Check fingerstick glucose - if low, give
• 50 mL D50 = 25g dextrose = 1 am D-glucose
• **hide**peds = dextrose 0.25 g/kg, max 25g, using 2.5 ml/kg of D10 (not D50; can extravasate/damage tissue), slowly (2-3 ml/min)
• Give thiamine 100 mg IV if c/f Wernicke's
• Narcan (naloxone) if suspicious for opioid overdose (heroin/pain meds, ↓RR)
• Goal - give enough to breathe adequately, not for full alertness
• Use slow titration: abrupt withdrawal → pain, agitation, tachycardia, HTN, n/v
• Rarely, flash pulmonary edema after large doses (CXR if concerned)
• Dosing
• 1 ampule = 0.4 mg in 10 mL 
• Opioid OD: 0.4 - 2 mg in slow IVP (IV pushes) q2-3 min (1-5 amps)
• Post-op (reversing anesthesia): 0.1-0.2 mg slow IVP q2-3 min (1/2 amp)
• If 5 amps doesn't fix it, reconsider Dx...
• Can give SQ/IM if no IV access, but slower absorption/delayed elimination
• Narcan will wear off (t1/2 ~ 90 min) before pain meds/heroin - may need to redose if recurrent hypoventilation
• Flumazenil (Romazicon) for benzos
• Use in reversing after procedural sedation
• Controversial in OD - does not consistently reverse resp. depression, may cause seizures...
• 0.2 mg slow IVP q1 min PRN (max 1 mg)
• Short duration of action - peak in 6-10 min; duration < 90 min

Acute agitation requiring intervention

• Assess need for additional staff/security; is patient at imminent risk of harm to self/others?
• Mitigate clear precipitating/aggravating factors, e.g. bad news, agitating visitors
• Physical restraints are a last resort!!
• Can try mittens; sleeve over IV if pulling at lines
• Sitter for constant observation
• Chemical restraints for agitation
• Treatment of delirium for further reading
• Typical agents in acute setting:
• Haldol 5 mg IM - watch for EPS, long QT (have QTc on monitor and keep Mg > 3)
• Ativan 2 mg PO - preferred for anxiety-related agitation, not for delirium (benzos don't help)